RESUME OF EMERGENCY TRACHEOTOMY
The following notes should be memorized.
1. Essentials: Knife and pair of hands (but full equipment better).
[295] 2. Don't do a laryngotomy, or stabbing.
3. "Two stage, finger guided" operation better.
4. Sand bag or substitute.
5. Press back danger lines with left thumb and middle finger, making
safety line and trachea prominent.
6. Memorize Jackson's tracheotomic triangle.
7. Incise exactly in middle line from Adam's apple to sternum.
8. Feel for tracheal corrugations with left index in pool of blood,
following trachea with finger downward from superficial Adam's apple.
9. Pass knife along index and incise trachea (not too deeply, may
cut posterior wall).
10. Don't mind bleeding; but keep middle line and keep head
straight; keep head low; don't bother about thyroid gland.
11. Don't expect hiss when trachea is cut if patient has stopped
breathing.
12. Start artificial respiration.
13. Amyl nitrite. Oxygen.
14. Practice palpation of the neck until the tracheal landmarks are
familiar.
15. Practice above technic, up to point of incision, at every
opportunity.
16. Jackson's tracheotomic triangle: A triangulation of the front
of the neck intended to facilitate a proper emergency tracheotomy.
Apex at suprasternal notch.
Sides anterior edge sternomastoids.
Base horizontal line lower edge cricoid.
RESUME OF AFTER-CARE OF A TRACHEOTOMIC CASE
1. Always bear in mind that tracheotomy is not an ultimate object. The ultimate object is to pipe air down into the lungs. Tracheotomy is only a means to that end. 2. Sterile tray beside bed should contain duplicate (exact) tracheotomy tube, Trousseau dilator, hemostat, thumb forceps, silver probe, scissors, scalpel, probe-pointed curved bistoury. Sterile gloves ready. 3. Special nursing necessary for safety. 4. Laxative. 5. Sponge away secretions before they are drawn in. 6. Cover wound with wide large gauze square slit so it fits around cannula under the tape holder. Pull off ravelings. Keep wet with 1 : 10,000 Bichloride solution. 7. Change dressing every hour or oftener. 8. Abundance of fresh air, temperature preferably about 70 degrees. 9. Nurse should remove inner cannula as often as needed and clean it with pipe cleaner before boiling. 10. Outer cannula should be changed every day by the surgeon or long-experienced tracheotomy nurse. A pilot should be used and care should be taken not to injure the cut ends of the tracheal cartilage. 11. A sterile, bent probe may be inserted downward in the trachea with both cannulae out to excite cough if necessary to expel secretions. An aspirating tube should be used, when necessary. 12. A patient with a properly fitted cannula free of secretions breathes noiselessly. Any sound demands immediate attention. 13. If the respiratory rate increase it is much more likely to be due to obstruction in, malposition of, or shortness of the cannula than to lung complications. 14. Be sure that: (a) The cannula is clear and clean. (b) The cannula is long enough to reach well down into the trachea. A cannula that was long enough when the operation was done may be too short after the cervical tissues swell. (c) The distal end of the cannula actually is deeply in the trachea. The only way to be sure is, when inserting the cannula, to spread the wound and the tracheal incision with a Trousseau dilator, then see the interior of the tracheal lumen and see the cannula enter therein. 15. If after attending to the above mentioned details there are still signs of obstructive dyspnea, a bronchoscopy should be done for finding and removal of the obstruction in the trachea or main bronchi. 16. If all the "pipes," natural and instrumental, are clear there can be no such thing as obstructive dyspnea. 17. Pneumonia and pulmonary edema may exist before tracheotomy, but they are rare sequelae. 18. Decannulation, in cases of tracheotomy done for temporary conditions should not be attempted until the patient has slept at least 3 nights with his cannula tightly corked. A properly fitted cannula (i.e. one not larger than half the area of cross section of the trachea) permits the by-passage of plenty of air. A partial cork should be worn for a few days first for testing and "weaning" a child away from the easier breathing through the neck. In cases of chronic laryngeal stenosis a prolonged test is necessary before attempting decannulation. 19. A tracheotomic case may be aphonic, hence unable to call for help. 20. The foregoing rules apply to the post-operative periods. After the wound has healed and a fistula is established, the patient, if not a child, may learn to care for his own cannula. [298] 21. Do not give cough-sedatives or narcotics. The cough reflex is the watch dog of the lungs.
NOTES ON NURSING TRACHEOTOMIZED PATIENTS
Bedside tray should contain:
Duplicate cannula
Scalpel
Trousseau dilator
Hemostat
Dressing forceps
Sterile vaseline
Scissors
Tape
Probe
Gauze sponges
Gauze squares
Probe-pointed curved bistoury.
1. Room should be abundantly ventilated, as free from dust and lint
as possible, and the air should be moistened by steam in winter.
2. Keep mouth clean. Tooth brush. Rinse alcohol 1:10.
3. Sponge away secretion after the cough before drawn in.
4. Remove inner cannula (not outer) as often as needed. Not less
often than every hour. Replace immediately. Never boil a cannula until
you have thoroughly cleaned it.
5. Obstruction of cannula calling for cleaning indicated by:
Blue or ashy color.
Indrawing at clavicles, sternal notch, epigastrium.
Noisy breathing. (Learn sound.)
6. Surgeon (in our cases) will change outer cannula once daily or
oftener.
7. Duplicate cannulae.
8. Be careful in cleaning cannulae not to damage.
9. Watch for loose parts on cannula.
10. Change dressing (in our cases) as often as soiled. Not less
often than every hour. Large squares. Never narrow strips.
11. Watch color of lips and ears and face.
[299] 12. Report at once if food or water leaks through wound.
(Coughing and choking).
13. Never leave a tracheotomized patient unwatched during the first
days or weeks, according to case.
14. Remember Trousseau dilator or hemostat will spread the tracheal
wound or fistula when cannula is out.
15. Remember life depends on a clear cannula if the patient gets no
air through the mouth.
16. Remember it takes very little to clog the small cannula of a
child.
17. Remember a tracheotomized patient cannot call for help.
18. Decannulation. Testing by corking partially. Watch corks
not too small, or broken. Attach them by braided silk
thread. Pure rubber cord ground down makes best cork.
[300] CHAPTER XXXVIII—CHRONIC STENOSIS OF THE LARYNX AND TRACHEA
The various forms of laryngeal stenosis for which tracheotomy or
intubation has been performed, and the difficulties encountered in
restoring the natural breathing, may be classified into the following
types:
1. Panic
2. Spasmodic
3. Paralytic
4. Ankylotic (arytenoid)
5. Neoplastic
6. Hyperplastic
7. Cicatricial
(a) Loss of cartilage
(b) Loss of muscular tissue
(c) Fibrous
Panic.—Nothing so terrifies a child as severe dyspnea; and the memory of previous struggles for air, together with the greater ease of breathing through the tracheotomic cannula than through even a normal larynx, incites in some cases so great a degree of fear that it may properly be called panic, when attempts at decannulation are made. Crying and possibly glottic spasm increase the difficulties.