is complete, exuberant granulations are apt to
form and occlude the trachea, perhaps necessitating a new tracheotomy
for dyspnea.

It is so important to fix indelibly in the mind the cardinal points
concerning tracheotomy that I have appended to this chapter the
teaching notes that I have been for years giving my classes of
students and practitioners, hundreds of whom have thanked me for
giving them the clear-cut conception of tracheotomy that enabled them,
when their turn came to do an emergency tracheotomy, to save human
life.

RESUME OF TRACHEOTOMY

_Instruments_.
Headlight
Sandbag
Scalpel
Hemostats
Small retractors
Tenaculum
Tracheotomic cannulae (proper kind)
Long.
Half area cross-section trachea.
Proper curve: Radius too short will press ant. tracheal wall; too
long, post. wall.
Sterling Silver
Tracheobronchial aspirator.
Probe.
Tapes for cannulae
Trousseau dilator
Sponges
Infiltration syringe and solution
Oxygen tank.

_Indications_: Laryngeal dyspnea.
(Indrawing guttural and clavicular fossae and at epigastrium.
Pallor. Restlessness. Drowning in his own secretions.)

Do it early. Don't wait for cyanosis.
[294] Never use general anesthesia on dyspneic patient.
Forget about "high" and "low" distinctions until trachea is exposed.
Memorize Jackson's tracheotomic triangle.
Patient recumbent, sand bag under shoulders or neck. Nose to zenith.
Infiltration, _Intra_dermatic.
Incise from Adam's apple to guttural fossa.
Hemostasis.
Keep in middle line.
Feel for trachea.
Expose isthmus of thyroid gland.
Draw it upward or downward or cut it.
Ligature, torsion, etc. before incising trachea.
Hold trachea with tenaculum.
Incise trachea below first ring.
Avoid cutting cricoid or first ring. Cut 3 rings vertically. Don't
hack. Don't cut posterior wall which almost touches the anterior wall
during cough. Spread carefully, with Trousseau dilator.
Insert cannula; _see_ it enter tracheal lumen; remove pilot; tie
tapes.
Don't suture wound. Dress with large squares.
Don't give morphine.
Decannulation by corking partially, after changing to smaller
cannula.
Do not remove cannula permanently until patient sleeps without
indrawing with corked cannula.

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