METHODS & TECHNIQUES education, tracheostomy, pediatric, model tracheostomy, pediatric, technique, model

Emergency Pediatric Tracheostomy: A Usable Technique and Model for Instruction

Tracheostomies, although rarely performed, may be necessary in cases in which a cricothyrotomy is precluded by the small size of the cricothyroid space in infants and small children, when there is a high-grade upper airway obstruction, or when massive neck swelling or laryngeal fractures obscure the cricothyroid landmarks. A new technique for emergency pediatric tra- cheostomy and a model for practicing the procedure in cats has been devel- oped. The technique uses a finder needle and a saline-filled syringe to locate the small and poorly defined trachea. Free-flowing saline or aspirated air bubbles indicate entrance of the locator needle into the tracheal lumen. A stabbing incision is made lateral to and against the needle, the stoma is spread, and an endotracheal tube is introduced. Kittens weighing 1,000 g to 1,500 g have a tracheal diameter of 5.5 m m to 6.0 ram, equivalent to a child less than 1 year old. Cats in the 2,000-g to 3,000-g range approximate the tracheal size for an older child. Either recently killed or anesthetized cats may be used. Using this model, emergency physicians can become more proficient in performing tracheostomies rapidly on small subjects. This tech- nique, however, has not been studied in human beings of the pediatric age group. [McLaughlin J, Iserson KV: Emergency pediatric tracheostomy: A us- able technique and model for instruction. Ann Emerg Med April 1986;15: 463-465.]

I N T R O D U C T I O N Emergency surgical access to the pediatric airway is neither routine nor

easy for most practitioners. An emergency tracheostomy may be necessary as a last resort in life-threatening situations in which cricothyrotomy and oral or nasal intubation are impossible. These circumstances include high- grade, upper-airway obstruction due to foreign body aspiration, epiglottitis and other causes of upper airway edema, facial and laryngeal fractures, laryngospasm, or apnea in a child with a possible cervical spine injury. Be- cause about 500 children less than 4 years old die each year in the United States from foreign body aspiration alone,1 any health care provider could be confronted with this management challenge. In an adult or older child, a cricothyrotomy would be indicated. The narrow cricothyroid space in infants and preschoolers, however, prevents use of this route. 2-s T h e often-recom- mended placement of needles into this space precludes suctioning, optimal ventilation, and protection from aspiration. 6-8

We propose a reliable, simplified technique for placing a secure airway into the pediatric trachea with readily available emergency equipment, and an animal for practicing this procedure.

T E C H N I Q U E To perform the tracheostomy using this technique, the midline of the neck

is located and the trachea is secured between the thumb and index finger of the nondominant hand. The overlying skin is incised transversely. A finder needle, attached to a saline-filled syringe, is used to locate and stabilize the tracheal lumen prior to incision and cannulation. The needle is inserted into the midline between the prominent thyroid cartilage and the sternal notch, aiming for the proximal portion of the trachea [Figure 1}. The saline is in- jected gently; when it flows without resistance, the trachea has been entered. Aspiration of air confirms correct positioning within the lumen.

James McLaughlin, MD Kenneth V Iserson, MD, FACEP Tucson, Arizona

From the Section of Emergency Medicine, Department of Surgery, University of Arizona Health Sciences Center, Tucson, Arizona.

Received for publication May 24, 1985. Revision received October 7, 1985. Accepted for publication November 4. 1985.

Presented at the University Association for Emergency Medicine Annual Meeting in Kansas City, Missouri, May 1985.

Address for reprints: Kenneth V tserson, MD, FACEE Section of Emergency Medicine, Department of Surgery, University of Arizona Health Sciences Center, 1501 North Campbell, Tucson, Arizona 85724.

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PEDIATRIC TRACHEOSTOMY McLaughlin & Iserson

While holding the needle steady, a vertical stabbing incision is made lat- eral to and against the needle (Figures 2A and 2B). Using the knife handle to open the stoma, the needle is removed and a standard endotracheal tube is in- serted (Figure 3). The tube is secured with tape and, if necessary, the wound is packed to control bleeding.

Recently killed cats are good mod- els for practicing this technique be- cause they are readily available at lit- tle or no cost from animal control centers and they do not require facili- ties for live animal care. Through au- topsy measurements, we have found that kittens weighing 1,000 g to 1,500 g have an anterior-posterior tracheal lumen of 5.5 mm to 6.0 mm. Com- parison to reported pediatric autopsy measurements indicates that the tra- cheal size of these animals is equiv- alent to those of children less than 1 year old (5.0 mm to 6.2 mm).9Ao Our measurements show the tracheal lumen of aduk cats (2,000 g to 3,000 g) to be 7.0 mm to 8.00 mm, which ap- proximates that of children 2 to 4 years old (7.6 mm to 9.4 lnrn). 9,10

The required equipment includes a S mL to 6 mL saline-filled syringe fit- ted to a 19- to 21-gauge, 1- to 1V4-inch needle, scalpels (number 15 blades for kittens or infants, and number 10 blades for adult cats or older children) and endotracheal tubes (4.0 mm to 4.5 mm for the kitten/infant and 5.0 mm to 55 mm for the cat/child).

This model also can be used to sim- ulate massive neck swelling due to bleeding or subcutaneous eymphy- sema in adults whose cricothyroid landmarks are obscured. When water or air is injected subcutaneously into the neck of a dog, the finder-needle

FIGURE 1. Incise skin, then insert needle into proximal trachea. Inject saline and aspirate to confirm correct placement in tracheal lumen.

FIGURES 2A and 2B. Steady the nee- dle and make a vertical tracheal inci- sion lateral to and against the needle.

tracheostomy technique is effective, although the prominent canine laryn- geal cartilage and trachea make Sur- gical access seem deceptively easy. The technique is the same as in the cat, but correspondingly larger scalpel blades (number 10 or number 20) and endotracheal tubes are used.

We have tested this model infor- mally with faculty and junior and se- nior emergency medicine residents. After a brief explanation and demon- stration, they were asked to perform a needle-guided tracheostomy. Most hesitated when confronted with the small and obscure feline landmarks, but then proceeded to establish an air- way. A second attempt markedly im- proved their confidence and speed, so that performance times were routinely less than one minute. We found that each animal could be used for two at- t empts , rea l iz ing tha t the more candad site would be less desirable in actual practice. Complications were not sought or recorded.

DISCUSSION Historical ly the indicat ions for

emergency t racheos tomy have in- cluded airway obstruction from for- eign bodies, infectious and anaphylac- tic edema of the neck, cervical tumors with airway obstruction, severe facial and laryngeal fractures, and apnea in

circumstances in which cervical spine injury is suspected.2, 7 Many methods have been suggested to manage these s i tuat ions , inc luding supposedly foolproof instruments that combine needles, knives, or trocars with an- nulas.6, 8 In adults, these devices have been replaced largely by cricothy- rotomy. Neither the devices nor cri- cothyrotomy, however, is suitable for small children. Tracheostomy is the optimal emergency airway for these patients. It enables excellent ventila- tion and suctioning and, because it is placed below the cricoid ring, it avoids the narrowest area of the young air- way.

In 1976, Gold and associates de- scribed the needle-guided tracheos- tomy as an acceptable approach in these dire situations in adults, n They used a number 11 scalpel blade and placed the incision candad from the finder needle. We had difficulty apply- ing this technique to our small model.

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We found that the blade could not be kept in the trachea reliably, probably because the target (trachea)becomes progressively deeper in the neck as one progresses distally. In addition, the number 11 blade often made too small an incision in the trachea to allow easy tube p lacement wi th in the lumen. By using a number 10 or number 15 blade placed lateral to the finder needle, we have resolved these problems in the animal model. The rounded scalpel blade assures a tra- cheal opening of sufficient size to place an endotraeheal tube. Our longi- tudinal tracheal incision avoids the potential for overcutting laterally. Use of the needle as a guide should reduce the risk of damage to adjacent struc- tures from blind incisions seeking poorly defined landmarks in the short, thick necks of infants and small chil- dren. We must emphasize that this technique has never been used in pe- diatric-age human subjects, but it does offer the unskilled operator a con- trolled approach to emergency tra- cheostomy.

The potential complications of per-

forming a tracheostomy using this method are serious but similar to those with a conventional tracheosto- my technique: bleeding; damage to such adjacent s t r uc tu r e s as the esophagus, thyroid, nerves, and mus- cles of the neck; and delayed obstruc- tion from granulation or stenosis. The risk of pneumothorax can be mini- mized by selecting a cephalad site for incision, preferably through the sec- ond-fourth tracheal rings. Our tech- nique has not been used in human beings, but the expected complica- tions would be the same.

C O N C L U S I O N Needle-guided t racheostomy ap-

pears to be a useful technique for ob- ta ining a surgical airway in the pediatric emergency patient. Practice wi th the feline model is recom- mended for achieving proficiency in this technique because few clinicians will see enough children requiring a surgical airway to obtain sufficient ex- perience in human beings. Although the technique is simple, we have found that repeated per formance

FIGURE 3. Use the scalpel handle to open the s t oma; inser t t he enclo- tracheal tube.

builds confidence and decreases oper- ating time. This teaching approach is used in the advanced trauma life sup- port procedures laboratory using the canine model. 12 Similarly, needle- guided tracheostomy could be incor- porated into advanced pediatric and trauma life support courses. With this readily available model, emergency physicians, surgeons, and pediatri- cians can become more proficient at performing a lifesaving tracheostomy when conservative airway manage- ment has failed.

REFERENCES 1. National Safety Council: Accident Facts. Chicago, National Safety Council, 1981.

2. Tucker JA: Obstruction of the major pediatric airway. Otolarygol Clin North Am 1979; 12:329-341.

3. Kress TD, Balsubramaniam S: Cri- cothyroidotomy. Ann Emerg Med 1982; 11:197-201.

4. Kastendieck J: Airway management, in Rosen P, Baker FG, Braen GR, et al (eds): Emergency Medic ine Concepts and Clinical Practice I. St Louis, CV Mosby Co, 1983, pp 26-53.

5. Rosen P, Barkin R: Pediatric respiratory distress, l Emerg Med 1983;1:81-82. 6. Ruhe DS, Williams GV, Proud GO: Emergency airway by cricothyroid punc- ture or tracheotomy. Tr Am Acad Ophth Otol 1960;64:182-203.

7. Joyce SM, Hedges JR: Advanced ap- proaches to airway access. Current Topics in Emergency Medicine 1983;2:1-9.

8. Shapiro SL: Emergency airway for acute laryngeal obstruction. Eye, Ear, Nose, and Throat Monthly 1979;49:35-40.

9. The International Commission on Ra- diological Protection No. 23: Report of the Task Force on Reference Man. Oxford, Pergamon Press, 1975, pp 156-157.

10. Eckenhoff J: Some anatomic consid- erations of the infant larynx influencing endotracheal intubation. Anesthesiology 1951;12:401-410.

11. Golden GT, Fox JW, Edlich RF: Emer- gency tracheostomy. Am J Surg 1976; 131: 766-767.

12. American College of Surgeons: Ad- vanced Trauma Life Support Course for Physicians - - Instructor Manual 1984. Chicago, American College of Surgeons, 1984.

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