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Cricothyroidotomy

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Synonym: Cricothyrotomy

This procedure provides a temporary emergency airway in situations where there is obstruction at or above the level of the larynx, such that oral/nasal endotracheal intubation is impossible. Compared to an emergency tracheostomy, it is quicker and easier to perform and associated with fewer complications.1 It is a relatively quick procedure, taking up to about 2 minutes to complete.2 In an emergency without access to medical equipment, cricothyroidotomy has even been improvised using a drinking straw and pen-knife.3

There are three techniques:

  • Needle
  • Intubation (with purpose-built kits)
  • Surgical

All require a good working knowledge of regional anatomy to be able to carry the procedure out safely and effectively. It should be used as a last resort, reserved for life-and-death situations and is best carried out by experienced hands, or under their instruction where possible. The techniques can be taught on animal or mannequin models4 but conditions in the 'field' are frequently much more challenging.

Indications2

Need for an emergency airway where:

  • Intubation is not possible via the oral or nasal route
  • Need to avoid neck manipulation (e.g. basal skull/cervical spine injury or fracture)
  • Severe maxillofacial trauma
  • Oedema of throat tissues preventing visualisation of the cords (e.g. angioneurotic oedema, anaphylaxis, burns, smoke inhalation)
  • Severe oropharyngeal/tracheobronchial haemorrhage
  • Foreign body in upper airway
  • Lack of equipment for endotracheal intubation
  • Technical failure of intubation
  • Severe trismus/clenched teeth
  • Masseter spasm after succinylcholine
Contraindications2
  • Availability of a less invasive means of securing the airway
  • Patients <5 years old (needle technique may be used but formal tracheostomy is preferred)
  • Laryngeal fracture
  • Pre-existing or acute laryngeal pathology
  • Tracheal transection with retraction of trachea into mediastinum
  • Anatomical landmarks obscured by gross haemorrhage/surgical emphysema etc.
Technique5

Needle cricothyroidotomy

A needle or cannula (usually a large bore IV cannula) is inserted through the cricothyroid membrane:

  • Place the patient supine and, assuming no cervical spine injury, extend the neck using a pillow under the shoulders
  • Run a finger down the front of the neck in mid-line and find the notch in the upper border of the thyroid cartilage. Below this is a depression between the thyroid and cricoid cartilages – the cricothyroid membrane.
    CRICOTHYROIDOTOMY (1) (OM1879a.jpg)
  • Stabilise the cricothyroid membrane with one hand between finger and thumb.
  • Pierce it with a large-bore cannula (14G) attached to a syringe aiming at 45° to the skin, caudally in the sagittal plain.
  • Aspirate as the needle is introduced and confirm position by withdrawal of air; slide cannula over needle into airway.
  • Connect to O2 supply via Y-connector - give 15 l/min for an adult or, in a child, set the gas flow to the age of the child in years.
  • Ventilate by covering the patent port of Y-connector with a thumb to allow O2 to flow for 1 second (transtracheal insufflation). Remove thumb to allow expiration for 4 seconds via the upper airway. If no Y-connector available, use 2 ml syringe or IV giving set with hole in the side that can be occluded by the thumb.
    CRICOTHYROIDOTOMY (2) (OM1879b.jpg)

Note, expiration is not possible through the cannula so with complete upper airway obstruction of the upper airway, reduce oxygen flow.
A needle cricothyroidotomy can usually only be used for 30–45 mins before CO2 retention becomes significant.

Cricothyroid intubation with purpose-built kits

Cricothyroidotomy may be achieved with a narrow tube using a pre-prepared kit such as the Mini Trach® II which contains a guarded blade, plastic introducer, 4mm uncuffed tube to slide over introducer, ISO connection, tracheal suction tube and neck fastenings. The patient can breathe spontaneously or be bagged using this form of airway, but they are usually only used as a temporary measure until a more permanent airway is secured. Retrograde intubation can be practised with a Mini Trach® II set by passing the introducer upwards into the mouth and feeding an endotracheal tube into place over it.6

Surgical cricothyroidotomy

This is usually not performed in children under 12.

  • Delineate anatomy as above, clean skin and instil local anaesthetic (if patient conscious).
  • Make a small vertical skin incision in midline, spread the wound edges laterally and identify cricothyroid membrane.
  • Take care not to cut or remove the thyroid or cricoid cartilages.
  • Make a horizontal incision through the membrane's inferior half and then extend gently through it.
  • Dilate the opening with curved forceps or rotation of inverted scalpel handle. Insert small, cuffed endotracheal tube or tracheotomy tube (max. 8mm).
  • Aim downwards as tube is inserted to avoid damage to vocal cords.
  • Inflate the tube cuff and confirm its position with visualisation of chest movements and auscultation over lungs and stomach.
  • Finally, secure the tube.
Complications

Although complications do occur they are minor when compared to the catastrophic outcome normally associated with a failure to secure an airway. Complications can affect up to 40% in the emergency situation, but in experienced hands the complication rate is usually much lower. Elective complication rate is ~ 6–8%.2

Complications

Techniques to prevent complication

Thyrohyoid membrane incision Attention to anatomy; vertical skin incision; confirm position cricothyroid membrane after skin incision.
Intra/postoperative bleeding Incise directly over cricothyroid membrane in midline; vertical skin incision; horizontal incision in inferior half membrane; avoid thyroid isthmus.
Subglottic stenosis Use small bore tube; avoid long-term use (>72 hrs).
Dysphonia/hoarseness Use small tube; point inferiorly to avoid cords; avoid tracheal cartilage damage by not using force.
Laryngeal damage Avoid oversized tube and excessive traction on thyroid cartilage during insertion.
Tube misplaced in bronchus Avoid insertion of too much of tube length so as not to enter right main bronchus.
Pulmonary aspiration Protect upper airway by suction and positioning.
Tracheal stenosis Use low-pressure balloon cuff.
Recurrent laryngeal nerve injury Stay in midline and avoid posterior subglottic wall by not inserting instruments too far.
Oesophageal perforation or tracheo-oesophageal fistula Do not incise or insert needle deeply after entering subglottic space.
Tracheo-left brachiocephalic vein fistula Use low-pressure cuff.
Fracture of thyroid cartilage Avoid oversized tube.
Prognosis

As cricothyroidotomy is usually performed as an emergency airway of last resort, patients receiving them tend to be critically ill. Unsurprisingly, one US study showed that only 27% of trauma patients receiving pre-hospital cricothyroidotomy survived to hospital discharge but 62% survived to Emergency Department admission, indicating reasonable utility as a holding emergency airway.7 Amongst longer term survivors, good functional status is unusual with frequent neurological disability.8


Document references
  1. Gerich TG, Schmidt U, Hubrich V, et al; Prehospital airway management in the acutely injured patient: the role of surgical cricothyrotomy revisited. J Trauma. 1998 Aug;45(2):312-4. [abstract]
  2. Boon JM, Abrahams PH, Meiring JH, et al; Cricothyroidotomy: a clinical anatomy review. Clin Anat. 2004 Sep;17(6):478-86. [abstract]
  3. Adams BD, Whitlock WL; Bystander cricothyroidotomy performed with an improvised airway. Mil Med. 2002 Jan;167(1):76-8. [abstract]
  4. Wong DT, Prabhu AJ, Coloma M, et al; What is the minimum training required for successful cricothyroidotomy?: a study in mannequins. Anesthesiology. 2003 Feb;98(2):349-53. [abstract]
  5. Advanced Paediatric Life Support, 4th Edition. Advanced Life Support Group. BMJ Books 2005
  6. Slots P, Vegger PB, Bettger H, et al; Retrograde intubation with a Mini-Trach II kit. Acta Anaesthesiol Scand. 2003 Mar;47(3):274-7. [abstract]
  7. Fortune JB, Judkins DG, Scanzaroli D, et al; Efficacy of prehospital surgical cricothyrotomy in trauma patients. J Trauma. 1997 May;42(5):832-6; discussion 837-8. [abstract]
  8. Isaacs JH Jr; Emergency cricothyrotomy: long-term results. Am Surg. 2001 Apr;67(4):346-9; discussion 349-50. [abstract]

Internet and further reading Acknowledgements EMIS is grateful to Dr Chloe Borton for writing this article and to Dr Sean Kavanagh for earlier versions. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2008.
DocID: 2017
Document Version: 20
DocRef: bgp1879
Last Updated: 17 Mar 2008
Review Date: 17 Mar 2010

The authors and editors of this article are employed to create accurate and up to date content reflecting reliable research evidence, guidance and best clinical practice. They are free from any commercial conflicts of interest. Find out more about updating.

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