Cricothyroidotomy

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Cricothyroidotomy, also known as cricothyrotomy, is an important emergency procedure that is used to obtain an airway when other, more routine methods (eg, laryngeal mask airway [LMA] and endotracheal intubation) are ineffective or contraindicated. Establishing an effective airway in the face of medical emergencies is a skill that healthcare providers must master to prevent patient morbidity or mortality.

Cricothyroidotomy is indicated upon failure to obtain an airway with traditional methods in the following situations:

Trauma causing oral, pharyngeal, or nasal hemorrhage

Facial muscle spasms or laryngospasm

Uncontrollable emesis

Upper airway stenosis or congenital deformities

Clenched teeth

Tumor, cancer, or another disease process or trauma causing mass effect

Airway obstruction indications include the following:

Oropharyngeal edema (eg, anaphylaxis)

Foreign body obstruction

The following are relative indications for cricothyroidotomy:

Cervical spine immobilization secondary to injury

Maxillofacial injuries

Nonemergent indications include the following:

Prolonged intubation

Maxillofacial, laryngeal, or oral surgery

Bronchoscopy ^{[12, 13, 14]}

The only absolute contraindication to surgical cricothyroidotomy is age, although the exact age at which a surgical cricothyrotomy can be safely performed is controversial and has not been well defined. Various sources list lower age limits ranging from 5 years ^[15] to 12 years ^[16] , and Pediatric Advanced Life Support (PALS) defines the pediatric airway as age 1-8 years.

The most conservative approach is to use 12 years as the cutoff age. In patients below this cutoff age, needle cricothyrotomy is indicated because infants and children younger than 12 years have a smaller cricothyroid membrane and a more funnel-shaped, rostral, and compliant larynx. ^[12]

A commercially available set has now been developed for minimally invasive cricothyroidotomy in infants (Quicktrach baby™). ^[22] The set consists of a plastic cannula over a metal needle for direct placement in the trachea. So far, however, this device has not been evaluated for its intended use.

A permanent tracheostomy should be placed within 24 hours. Needle cricothyrotomy can be used for approximately 40 minutes, after which time carbon dioxide accumulates; this can be particularly devastating in patients with head trauma. ^{[12, 20]} In addition, stomas maintained via cricothyroidotomy for more than 2 days are associated with a higher risk of glottic and subglottic stenosis than tracheostomies are. ^[13]

In a 2005 study comparing the Seldinger technique with the standard surgical technique (see Technique), the time to tracheal puncture and ventilation was significantly longer with the latter. In addition, injury to the thyroid vasculature was more common with the standard surgical technique. ^[21]

Success rates for intubations performed in the emergency department (ED) are high; rescue cricothyrotomy is required in only 0.7% of adult patients ^[1] and in fewer than 1% of pediatric patients. ^[2]

The success rate for cricothyrotomy has been similarly high (89%-100%) in most of the studies done to date, ^{[3, 4, 5, 6, 7, 8, 9, 10]} whether in the field or in the ED, though 1 study reported a success rate of only 62.5%. ^[11] One study found a failed ED cricothyrotomy rate of 3.6% ^[8] ; earlier ED studies documented failure rates ranging from 7.9% to 10%. ^{[4, 5]}

A meta-analysis that sought to determine pooled estimates of the success rates of alternative airway devices, needle cricothyroidotomy, and surgical cricothyroidotomy found that needle cricothyroidotomy had a comparatively low rate of success (65.8%) but that surgical cricothyroidotomy had a much higher success rate (90.5%) and should be considered the preferred approach. ^[23]

The thyroid gland is ensheathed by the visceral fascia, a division of the middle layer of deep cervical fascia, which attaches it firmly to the laryngoskeleton. The anterior suspensory ligament extends from the superior-medial aspect of each thyroid lobe to the cricoid and thyroid cartilage. The posteromedial aspect of the gland is attached to the side of the cricoid cartilage, first and second tracheal ring, by the posterior suspensory ligament (ie, Berry ligament). This firm attachment of the gland to the laryngoskeleton is responsible for movement of the thyroid gland and related structures during swallowing.

For more information about the relevant anatomy, see Thyroid Anatomy.

For surgical cricothyroidotomy, materials needed include the following:

Antiseptic preparation solution

Lidocaine

Sterile drape/gown/gloves

No. 11 scalpel blade

Syringe (10 mL)

Bag-valve mask

Trousseau dilator

Tracheal hook

Tracheostomy tube or endotracheal tube

On average, the adult cricothyroid membrane is 9 mm vertically and 30 mm horizontally. Endotracheal tubes with inner diameters of 6 mm and 8 mm have outer diameters of 8.2 mm and 10.9 mm, respectively. The No. 4 Shiley tracheostomy tube has a 5-mm inner diameter and a 9.4-mm outer diameter, whereas the No. 6 has a 6.4-mm inner diameter and a 10.8-mm outer diameter. ^[12] Each tube comes with an outer cuffed cannula (cuffed tubes are recommended), an inner cannula, and an obturator.

For needle cricothyrotomy, materials needed include the following:

Antiseptic solution

Lidocaine

Sterile materials

Angiographic catheter (14 gauge or larger)

Syringe (10 mL) filled with 5 mL of normal saline

Pediatric endotracheal tube or modified intravenous (IV) extension set for transtracheal jet insufflations (3-mm endotracheal tube adapter with a Y-connector) ^[15]

For percutaneous cricothyrotomy using the Seldinger technique, materials needed include a finder needle with a dilator and a guide wire (available in cricothyrotomy kits).

In an emergency situation, there is little time to provide anesthesia. Often, anesthesia is an unnecessary step that interferes with the acquisition of an emergency airway. If anesthesia is indicated, local anesthesia using 1% lidocaine without epinephrine is appropriate.

The patient should be placed supine with the neck in the neutral position and medical personnel standing on the patient’s right side. C-spine immobilization should be applied if indicated.

There are 3 main approaches to cricothyroidotomy: needle cricothyroidotomy, percutaneous cricothyroidotomy using the Seldinger technique, and surgical cricothyroidotomy (see the videos below).

Needle cricothyroidotomy may be divided into the following steps:

Position the patient, apply lidocaine (if indicated), and prepare a sterile field, including cleansing with antiseptic solution.

Identify anatomic landmarks (see the images below). Palpate the thyroid cartilage (the first prominent landmark on the anterior neck), the cricoid cartilage (caudal to the thyroid cartilage), and the area between them, which is the cricothyroid space that contains the membrane. With the nondominant hand, stabilize the area using the first and third digits to either side of the thyroid cartilage, leaving the index finger to palpate the membrane.

With the dominant hand, insert the angiographic catheter, attached to the syringe filled with normal saline, into the cricothyroid membrane, directing it caudally at a 45^o angle.

As the needle is advanced, apply negative pressure to the syringe. A distinct pop can be felt as the needle traverses the membrane and enters the trachea. In addition, air bubbles will appear in the fluid-filled syringe.

Advance the catheter, and retract the needle.

Attach the jet ventilation device, and ventilate at 40-50 lb per square inch or 15 L/min. If this device is unavailable, attach the barrel of a 3-mL syringe to the catheter, and place an endotracheal tube adapter. A bag valve mask (BVM) can then be attached to deliver oxygen for ventilation.

Percutaneous cricothyroidotomy using the Seldinger technique may be divided into the following steps:

Follow steps 1-4 from needle cricothyroidotomy (see above), substituting a finder needle attached to a syringe for the angiographic catheter.

Remove the syringe from the needle, and advance the guide wire through the needle. Remove the needle once the guide wire is in place.

Use the scalpel to make a small stab incision in the skin close to the guide wire.

Place the dilator into the airway catheter, and insert the 2 devices together over the wire.

Remove both the dilator and the guide wire once the airway tube is secured in the trachea.

Secure the tube in place with appropriate tape.

Surgical cricothyroidotomy (see the video below) may be divided into the following steps:

See the list below:

Follow steps 1-2 from needle cricothyroidotomy (see above).

With the dominant hand, make a midline vertical incision, approximately 3 cm long and skin deep, over the cricothyroid membrane. A midline vertical incision may result in a small amount of venous bleeding but avoids the laterally located vasculature of the neck.

Palpate the cricothyroid membrane through the incision, using the index of the nondominant hand. Make a horizontal stab incision through the membrane. A distinct pop will be felt as the scalpel pierces the membrane and enters the trachea.

An assistant should insert the tracheal hook at the superior end of the incision and retract the skin and membrane cephalad. Keep the scalpel in place until the tracheal hook is inserted. If the incision is lost, the location can be identified by means of air bubbles produced during exhalation. If the patient is apneic, apply pressure to the anterior chest wall to simulate exhalation and thereby produce air bubbles.

Dilate the incision vertically, using the Trousseau dilator with the nondominant hand.

With the dominant hand, insert the tracheostomy tube between the 2 blades of the dilator, directing it initially to one side of the patient. Once the tube is through the membrane, rotate it 90^o and insert caudally.

Remove the obturator, and insert the inner cannula. Lock it into place.

Inflate the balloon with 5-10 mL of air. Attach the tube to a BVM and ventilate.

Confirm placement through observation of chest rise, auscultation, and assessment of end-tidal CO₂.

Remove the tracheal hook, and secure the tube in place. ^{[12, 17, 15]}

Another approach to cricothyroidotomy is called the rapid 4-step technique (RFST). This technique involves a scalpel, a tracheal hook, and a tracheostomy tube and consists of the following 4 steps: palpation, stab incision, inferior traction, and tube insertion. ^[18] Although the RFST is faster than the standard surgical technique, it has been shown to have a higher complication rate. ^[19]

Early complications of cricothyroidotomy may include the following:

Bleeding

Incorrect placement, resulting in possible creation of a false passage through tissue

Subcutaneous emphysema

Obstruction

Esophageal or mediastinal perforation

Aspiration

Vocal cord injury

Pneumothorax

Laryngeal injury

Posterior tracheal wall perforation

Thyroid perforation

Hypercarbia (needle cricothyroidotomy)

Late complications of cricothyroidotomy may include the following:

Dysphonia

Infections

Hematoma

Persistent stoma

Scarring

Glottic or subglottic stenosis

Laryngeal stenosis

Tracheoesophageal fistula

Tracheomalacia ^{[12, 14, 13]}

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Schaumann N, Lorenz V, Schellongowski P, Staudinger T, Locker GJ, Burgmann H, et al. Evaluation of Seldinger technique emergency cricothyroidotomy versus standard surgical cricothyroidotomy in 200 cadavers. Anesthesiology. 2005 Jan. 102(1):7-11. [Medline].

Metterlein T, Frommer M, Kwok P, Lyer S, Graf BM, Sinner B. Emergency cricothyrotomy in infants–evaluation of a novel device in an animal model. Paediatr Anaesth. 2011 Feb. 21(2):104-9. [Medline].

Hubble MW, Wilfong DA, Brown LH, Hertelendy A, Benner RW. A meta-analysis of prehospital airway control techniques part II: alternative airway devices and cricothyrotomy success rates. Prehosp Emerg Care. 2010 Oct-Dec. 14(4):515-30. [Medline].

Huma Khan, MD Resident Physician, Department of Emergency Medicine, Northshore-Long Island Jewish Medical Center

Disclosure: Nothing to disclose.

Gino A Farina, MD, FACEP, FAAEM Professor of Emergency Medicine, Hofstra North Shore-LIJ School of Medicine at Hofstra University; Program Director, Department of Emergency Medicine, Long Island Jewish Medical Center

Gino A Farina, MD, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;Cliexa;Preacute Population Health Management;The Physicians Edge<br/>Received income in an amount equal to or greater than $250 from: The Physicians Edge, Cliexa<br/> Received stock from RxRevu; Received ownership interest from Cerescan for consulting; for: Rxblockchain;Bridge Health.

Cricothyroidotomy

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