Performing an emergency tracheostomy

(Originally posted under "How to perform a tracheostomy")

Okay, let's make something very clear from the off. You DO NOT want to have to do this. I don't know why some people fantasise about the opportunity to briefly flourish their Bic biro at a cooing audience before plunging into the neck of some poor choking person (who just happens to be young, attractive, and of the appropriate sexual persuasion), immediately relieving their discomfort and securing their eternal gratitude... and possibly even a date so that they can really express their gratitude.

Okay, so I do know why some people fantasise about doing this. But before I explain how to do this, let me also explain why you don't want to ever have to.

1) One word: litigation. I have medical litigation insurance and even I don't want to ever have to do this. Just because you save someone's life (and this is a life-saving procedure), it doesn't mean they're not going to sue the pants off you as soon as they've recovered. Or even worse, they still die and their family sue you because there was a chance that you contributed toward their death.

2) This is a very important consideration: you might do it wrong. And lets face it, unless you are a trained paramedic / nurse / doctor, there's a very good chance you are going to do it wrong. The neck is full of very important bits and pieces; if you miss the right spot you are going to do a lot of damage. Results of an inexpert attempt at tracheostomy include, and are not limited to, paralysis of the vocal cords, perforation of the oesophagus and nicks to the carotid arteries resulting in a stroke and / or exsanguination.

3) Another possible outcome to all this will be you being charged with assault (that's if they live; if they die you're risking manslaughter). Yes, I know, you just saved their life and all, but you also just stabbed them a good one with the biro that you usually use to stir your morning coffee. Just be aware that you are risking criminal charges by doing this.

That said, this is a life-saving procedure, and sometimes in life, you gotta do what you gotta do and damn the consequences. A blocked airway is a very serious condition, and most people are dead within the two minutes from when it occurs. So what are the scenarios where you may need to perform an emergency tracheostomy? Well, for a start, let me clear up a small confusion. You will not be performing a tracheostomy, you will be performing a procedure known as a cricothyroidotomy (ER speak: cric-stick). A tracheostomy is a surgical incision into the first, second, third and fourth tracheal cartilage rings, which are situated well below the Adam's apple. It is a difficult procedure, and certainly not advisable to attempt with a biro. A cric-stick however, as I'll explain in a minute, is performed just below the Adam's apple, and is a lot safer than a tracheostomy. But back to the original question. When would you find yourself needing to perform an emergency cricothyroidotomy? Well, for the average man on the street, there'll only be three instances where a cric-stick'll be an appropriate procedure to perform.

1. The person has suffered a severe allergic reaction to something (e.g., bee sting, peanut allergy, etc.), causing their throat to swell up and cut-off their oxygen supply. In these instances, a cric-stick is life saving and should be performed without delay.


2. The person has been the victim of burns to the face and mouth, causing oedematous swelling of their throat. Again, a cric-stick is a life saving manoeuvre, but be aware that the patient will probably be having other difficulties with their breathing due to inhalation of smoke, carbon monoxide and other toxins.


3. The person is choking. Now this is a tricky one: be very sure that you've done everything possible to dislodge the foreign object already. For those who aren't up to date on their St. John Ambulance training, this is the run down:
   
   
   • Do NOT probe into their mouth and throat with your finger. You can make the situation worse by pushing the object further down the windpipe, and by causing a gag reflex that could result in them aspirating their own vomit, which really isn't at all fun. Trust me on this one.
   
   
   • Give them some hearty slaps on the back and encourage them to cough up the object on their own - on an adult this is best done standing up and leaning forward. On a child, have them lying on across your lap with their head lower than their chest. Do this five times in rapid succession. If they are able to move air in and out of their lungs (e.g., coughing or able to make some kind of noise) then keep encouraging them to cough the object up, but otherwise leave them alone to sort themselves out. If they are grabbing at their throat and are silent (i.e., not able to move any air in or out of their lungs) then the Heimlich manoeuvre is probably necessary.
   
   
   • If the person is still able to stand, grab them around the waist from behind. Grip your wrists together directly below the bottom of the centre of their ribcage and give five short, sharp, upward hugs. In children and those unable to stand, kneel next to their pelvis while they lie on their back, and place both hands below the bottom of the ribcage and give five short, sharp, upward (toward the head) thrusts. In children younger than a year, do not give a Heimlich; instead, while the child lies on its back, give five downward thrusts over their ribcage.
   
   
   • If this hasn't worked, give them another five back slaps. If that doesn't work, give another attempt at the Heimlich. If that doesn't work, it's probably time to move to the cric-stick, but only do a cric-stick if you are confident you can do it; otherwise keep cycling through the back-slap / Heimlich combination.
   
   Now, before you give the gung-ho side of you full rein, I should warn you of one thing; unless the obstruction is above the level of the Adam's apple, your doing a cric-stick is probably not going to do much good. But this doesn't mean you shouldn't try... just don't expect that you are going to save their life by doing it.

Okay, onto the cric-stick itself. First off, a cric-stick should only be performed on those over the age of 12 years. For those younger than this, a needle cricothyroid puncture should be performed instead, but desperate circumstances call for desperate measures, and in most situations outside of a hospital the appropriate equipment to perform a needle cricothyroid puncture will not be available so just do what you can. Like I've said before, this is life or death. I'm not going to put in how to perform a needle cricothyroid puncture because it is a little more complicated. If you're desperate to find out, there are courses you can do to learn that kind of shit...

Depending on the situation, you will have access to a limited variety of different pieces of equipment, so make do with the best of what you have. The basics that you should be able to scrounge up, wherever you are, are:

• a pen
• a sharp (as possible) knife or razor blade

If at all possible, what you'd really like to get your hands on are:

• a pen
• iodine or other disinfectant
• a pair of latex gloves (unless the patient or you have a latex allergy, in which case try and find a pair of non-latex gloves)
• a sharp knife or preferably a scalpel
• clean tissues or preferably sterile gauze
• a piece of crush-resistant, flexible tubing with as wide a diameter as possible (up to around 1cm)

Before all this begins, make sure that the emergency service have been alerted and are on-route as we speak. Now, first off, extend the person's neck while controlling the head; if there are other people around, get someone to hold the head for you, but if you are alone, kneel at the patients head (looking down their body) and rest their head between your knees.

To be brutally honest, by this point the patient has probably passed out from lack of oxygen. Like I said before, a blocked airway is a very quick route to the morgue. However, if they haven't, keep talking to them and reassuring them about what it is you're doing. Don't do anything without telling them first that you're going to do it. This procedure is a lot easier to do if they've passed out though; not least because most people who are conscious are not going to be happy about people going at their neck with a sharp knife. They have a tendency to flinch, resulting you cutting something that you probably shouldn't.

So, with the person's neck extended, feel along the midline of the throat. What you should be able to feel is something like this (please ignore the incredibly poor ASCII art, if anyone can do better, your contribution will be gratefully received!):

Head
                                                   |
           _________________/
         /
        |
         \
          |   <------ Adam's apple (also called the Thyroid cartilage)
         /
        |   <------- small soft spot
         \
           )   <------ Cricoid cartilage
          |
           \
Chest

With your pen, mark the skin overlying the soft spot - this is the bit that you're going to be cutting into, the cricothyroid membrane. Swab the area with either iodine or antiseptic solution, and put gloves on if you have them. While using one hand to tighten the overlying skin (by putting a finger to each side rather than above and below), pick up your 'sharp as possible' knife and make a small incision running left to right over the spot that you previously marked with your pen. Carefully enlarge this incision to just over half an inch in size till you can see the cricothyroid membrane underneath. There should be very little bleeding because you're nowhere near any large blood vessels at the moment, but any blood that has been spilled wipe away with a clean tissue / sterile gauze.

Now make a left to right incision in the cricothyroid membrane. Enlarge this by sticking a blunt object in the incision; the end of the scalpel's favourite, but the pen or even your finger will do in a pinch. When the hole's large enough to put the plastic tubing in, do so. If you don't have any tubing, then remove the ink tube centre of the ballpoint pen and break off the blunt end and stick the resulting tube into the cricothyroidotomy that you have created. Other things that can be used are straws or rolled-up cardboard tubes. Anything that can open the airway, basically.

Now, hopefully the patient should now begin to breathe by themselves, but if not, start CPR. Give them breaths via the inserted piece of tubing, and monitor their heart rate; start giving compressions if the heart rate drops below 40 beats per minute. Continue doing this until paramedics or other help arrives.

Curiosity sated? Information taken on-board? Good. Why are you still reading then?

Ah.

You want to know what to do when you can't find a knife. Well. Please tell me that if you're at this point you've at least tried to find a knife or other sharp implement; you're doing this to save a life y'know. Okay, same as before, extend the neck and mark the soft spot. Now, clutch the pen (with the ink tube still inside; you're going to need all the help you can get) very tightly in your fist around an inch and a half away from the point, and raise your arm. The next bit requires a good aim and a lot of balls. Bring the point of the pen down as hard as possible on the spot that you marked out. If you're lucky, you've done this with enough force to break through the skin and membrane, but not enough that you've carried on straight through the oesophagus and spine. Now pull the pen out, remove the ink tube and blunt end, and place the empty pen tube into the hole you made. If you're lucky, you haven't killed your patient by breaking their neck, and more than that, they should now be able to breathe.

Hurrah!

Addendum:
Doyle has very rightly pointed out how hard it is to breath through a straw / pen. Try it yourself sometime - it's not easy. I should make it very clear that this w/u is intended as a quick rundown of what to do in what is an emergency situation. A cric-stick performed outside of a hospital is only ever a tempory measure, and it needs to be replaced by something more permanent as soon as possible; within 20mins if you have any hope in preventing any brain damage occuring. So: only use a biro if desperate and there's nothing more appropriate to hand. The larger the diameter of the tube that you place in the throat, the easier it will be to get air into the person's lungs. Also be aware that the patient will probably not be able to breathe on their own through the tube, and that you will need to breathe into the tube for them to get oxygen into their lungs.

Whatever you do, do not neglect to phone an ambulance as soon as you realise that someone has blocked their airway; every second really does count. The ambulance crew would prefer to arrive to find a person who had been choking, but managed to dislodge the blockage either on their own or by using the Heimlich, than to be delayed for those five minutes where everyone thinks the person will clear it on their own, and then drops to the floor and is brain damaged or dies from lack of oxygen.