Surgical cricothyrotomy: Difference between revisions

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==Indications==
==Indications==
Necessity for a definitive airway and inability to quickly secure the airway through oral or nasotracheal intubation.
[[File:F8.png|thumb|External views of the larynx: (a) anterior aspect; (b) anterolateral aspect with the thyroid gland and cricothyroid ligament removed.]]
[[File:Larynx external Cricothyrotomy.gif|thumb|Landmarks for Cricothyrotomy]]
[[File:Cartilages and ligaments of the larynx.png|thumb|The cartilages and ligaments of the larynx seen posteriorly.]]
*'Can't intubate, can't ventilate'
**Need to secure an airway and cannot do so by non-surgical means
*Relevant clinical scenarios:
**Choking event with food bolus located above cricothyroid membrane
**Anaphylaxis requiring airway intervention but unable to pass tube from above
**Severe facial trauma or burns with distorted anatomy
**Failed airway


==Contraindications==
==Contraindications==
*No absolute contraindications in adults<ref>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.</ref>
*In infants and young children, [[Needle Cricothyrotomy]] may be preferred
**Cutoff age is debated
***Young as 5 in some sources<ref>King, C., Henretig, F.M. (2008). Textbook of Pediatric Emergency Procedures.</ref>
***10 or 12 years of age in other
===Relative Contraindications===
*Inability to identify the landmarks.
*Inability to identify the landmarks.
*Underlying anatomical abnormality.
*Underlying anatomical abnormality.
*Tracheal transection.
*Tracheal transection or severe trauma.
*Children < 10 years of age.
 
{{Difficult cricothyrotomy SHORT}}


==Materials==
==Materials==
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*Trousseau dilator
*Trousseau dilator
*Tracheal hook
*Tracheal hook
*[[Bougie]]
*Cuffed No. 4 Tracheostomy Tube or size 6 ETT
*Cuffed No. 4 Tracheostomy Tube or size 6 ETT
*4 x 4 gauze
*4 x 4 gauze
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==Procedure==
==Procedure==
[[File:Ant Neck Cric.png|thumb|Anterior neck anatomy with site of initial surgical cricothyrotomy incision (red line).]]
[[File:Larynx external Cricothyrotomy.gif|thumb|Landmarks for Cricothyrotomy]]
[[File:Surgical cricothyrotomy.JPG|thumb]]
===Scalpel-[[Bougie]] Technique:===
Note that this technique is preferred as it requires no specialized equipment and can be performed quickly relative to other techniques
*Identify landmarks as in other techniques
*Prep the neck as in other techniques
*Stabilize larynx with left hand
*Make a 4 cm vertical incision at neck midline over cricothyroid membrane
*Palpate cricothyroid membrane with left index finger
*Make a horizontal incision into the cricothyroid membrane and dilate using finger or scalpel
*Insert left index finger into trachea
*Pass [[bougie]] over left index finger into trachea
*Pass endotracheal tube over bougie just until balloon is no longer visible
*Inflate balloon
*Secure tube and confirm placement as with other techniques
===Standard Technique:===
===Standard Technique:===
#*'''Identify the Landmarks'''
*'''Identify the Landmarks'''
*Starting at the Sternal Notch, palpate superiorly until the Laryngeal Prominence is felt. The Cricothyroid Membrane will be approx one fingerbreadth below this.
**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.
**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'''
*'''Prepare the Neck'''
*Clean the neck with antiseptic. If time allows, infiltrate the skin and soft tissue with Lidocaine.
**Clean the neck with antiseptic. If time allows, infiltrate the skin and soft tissue with Lidocaine.
#'''Stabilize the Larynx'''
*'''Stabilize the Larynx'''
*Note: This is ESSENTIAL to success.
**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.
**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'''
*'''Incise the Skin'''
*With your dominant hand, make a 3.5 cm midline VERTICAL incision over the membrane.
**With your dominant hand, make a 3.5 cm midline VERTICAL incision over the membrane.
#'''Re-identify the Membrane'''
*'''Re-identify the Membrane'''
*Use the non-dominant index finger to again relocate the membrane.
**Use the non-dominant index finger to again relocate the membrane.
#'''Incise the Membrane'''
*'''Incise the Membrane'''
*Make a 1 cm HORIZONTAL incision on the lower edge of 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.
**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.
**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.'''
*'''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'''
*'''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).
**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'''
*'''Insert the Trousseau Dilator'''
*With your dominant hand, insert the dilator into the incision and GENTLY enlarge the incision in a vertical direction.
**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.'''
*'''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.
**Note: A gum elastic bougie may be used in place of the above tubes.
#'''Inflate the cuff and confirm placement.'''
*'''Inflate the cuff and confirm placement.'''


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


==Complications==
==Complications==
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*Subcutaneous emphysema
*Subcutaneous emphysema


== See Also ==
==See Also==
[[Intubation]]<br />
*[[Intubation]]
[[Needle Cricothyrotomy]]
*[[Difficult airway algorithm]]
*[[Surgical airways]]
 
==External Links==
*[https://www.merckmanuals.com/professional/critical-care-medicine/respiratory-arrest/surgical-airway#v28605119 Merk Manual - Surgical Airway]
*[http://www.emdocs.net/unlocking-common-ed-procedures-bougie-nights-the-surgical-airway-revisited/ emDocs - Bougie Nights: The Surgical Airway Revisited]
 
===Videos===
*EMCrit (0:50) https://www.youtube.com/watch?v=Q0RVlgwC9rs&feature=emb_logo
*EMCrit (0:58) https://www.youtube.com/watch?v=WnTBm5f_ihQ&feature=emb_logo
*Henneman (6:59) https://www.youtube.com/watch?v=bIbl6zgWBjg&feature=emb_logo


==References==
==References==
<references/>


 
[[Category:Critical Care]]
[[Category:Airway/Resus]]
[[Category:Procedures]]
[[Category:Procedures]]

Latest revision as of 21:35, 17 April 2024

Indications

External views of the larynx: (a) anterior aspect; (b) anterolateral aspect with the thyroid gland and cricothyroid ligament removed.
The cartilages and ligaments of the larynx seen posteriorly.
  • 'Can't intubate, can't ventilate'
    • Need to secure an airway and cannot do so by non-surgical means
  • Relevant clinical scenarios:
    • Choking event with food bolus located above cricothyroid membrane
    • Anaphylaxis requiring airway intervention but unable to pass tube from above
    • Severe facial trauma or burns with distorted anatomy
    • Failed airway

Contraindications

  • No absolute contraindications in adults[1]
  • In infants and young children, Needle Cricothyrotomy may be preferred
    • Cutoff age is debated
      • Young as 5 in some sources[2]
      • 10 or 12 years of age in other

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
  • Bougie
  • Cuffed No. 4 Tracheostomy Tube or size 6 ETT
  • 4 x 4 gauze
  • Surgical drape
  • Antiseptic solution

Procedure

Anterior neck anatomy with site of initial surgical cricothyrotomy incision (red line).
Landmarks for Cricothyrotomy
Surgical cricothyrotomy.JPG

Scalpel-Bougie Technique:

Note that this technique is preferred as it requires no specialized equipment and can be performed quickly relative to other techniques

  • Identify landmarks as in other techniques
  • Prep the neck as in other techniques
  • Stabilize larynx with left hand
  • Make a 4 cm vertical incision at neck midline over cricothyroid membrane
  • Palpate cricothyroid membrane with left index finger
  • Make a horizontal incision into the cricothyroid membrane and dilate using finger or scalpel
  • Insert left index finger into trachea
  • Pass bougie over left index finger into trachea
  • Pass endotracheal tube over bougie just until balloon is no longer visible
  • Inflate balloon
  • Secure tube and confirm placement as with other techniques

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

External Links

Videos

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.
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