Surgical cricothyrotomy

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Indications

  • Need for a definitive airway and inability to quickly secure the airway or maintain oxygenation through less invasive means.
Landmarks for Cricothyrotomy

Contraindications

  • No absolute contraindications in adults![1]
  • In infants and young children, Needle Cricothyrotomy is preferred due to anatomic differences. Cutoff age is debated, and ranges from as young as 5 in some sources[2], to 10 or 12 years of age in others.

Relative Contraindications

  • Inability to identify the landmarks.
  • Underlying anatomical abnormality.
  • Tracheal transection or severe trauma.

Predictors of Difficult Cricothyrotomy (SHORT)

  • Surgery
  • Hematoma
  • Obesity
  • Radiation (Burn or other distortion)
  • Tumor

Materials

  • No. 11 blade scalpel
  • Trousseau dilator
  • Tracheal hook
  • Cuffed No. 4 Tracheostomy Tube or size 6 ETT
  • 4 x 4 gauze
  • Surgical drape
  • Antiseptic solution

Procedure

Standard Technique:

  • Identify the Landmarks
    • Starting at the Sternal Notch, palpate superiorly until the Laryngeal Prominence is felt. The Cricothyroid Membrane will be approximately one fingerbreadth below this.
    • If not palpable with the prior method, place four fingers longitudinally across the neck with the 5th finger on the Sternal Notch. The Cricothyroid Membrane will be below your Index finger.
  • Prepare the Neck
    • Clean the neck with antiseptic. If time allows, infiltrate the skin and soft tissue with Lidocaine.
  • Stabilize the Larynx
    • Note: This is ESSENTIAL to success.
    • With the thumb and middle finger of the non-dominant hand, grip the posterolateral aspects of the Larynx, while leaving your index finger free to re-palpate the Cricothyroid membrane at any time.
  • Incise the Skin
    • With your dominant hand, make a 3.5 cm midline VERTICAL incision over the membrane.
  • Re-identify the Membrane
    • Use the non-dominant index finger to again relocate the membrane.
  • Incise the Membrane
    • Make a 1 cm HORIZONTAL incision on the lower edge of the membrane.
    • Note: The Cricothyroid vessels lie on the superior edge of the membrane. Making a lower incision helps avoid these vessels.
    • Aim the scalpel caudally to avoid injuring the vocal cords.
  • Once you have made the incision, slide the index finger of your non-dominant hand into the incision so as to not lose the opening.
  • Insert the Tracheal Hook
    • With your dominant hand, insert the hook TRANSVERSLY. Then, rotate it 90 degrees, so that the hook is oriented cephalad and lift the Larynx upward and cephalad. The hook may now be switched to your non-dominant hand or held by an assistant (preferable).
  • Insert the Trousseau Dilator
    • With your dominant hand, insert the dilator into the incision and GENTLY enlarge the incision in a vertical direction.
  • Remove the dilator place the tracheostomy (or endotracheal) tube over your finger and into the opening.
    • Note: A gum elastic bougie may be used in place of the above tubes.
  • Inflate the cuff and confirm placement.

Four-Step Technique:

  1. Identify the landmarks (as in the Standard Technique)
  2. Make a 1-2 cm HORIZONTAL stab incision through both the skin and cricothyroid membrane.
  3. BEFORE removing the scalpel, insert a tracheal hook and direct it caudally.
  4. Insert the tracheostomy tube through the incision into the trachea.

Complications

  • Incorrect placement
  • Bleeding
  • Esophageal or mediastinal perforation
  • Aspiration
  • Vocal cord or laryngeal injury
  • Thyroid injury
  • Subcutaneous emphysema

See Also

References

  1. In Roberts, J. R., In Custalow, C. B., In Thomsen, T. W., & In Hedges, J. R. (2014). Roberts and Hedges' clinical procedures in emergency medicine.
  2. King, C., Henretig, F.M. (2008). Textbook of Pediatric Emergency Procedures.