Background
A 2002 study of the National Emergency Airway Registry database found that only 0.56% (43 of 7712) of intubations required cricothyroidotomy (cricothyrotomy). [1, 2, 3] This percentage may be driven even lower by increasing adoption of rapid sequence intubation techniques, increased use of video-assisted intubation and other "difficult airway" devices, and increased prevalence of residency-trained emergency practitioners. [4] However, some patients still require a surgical airway. [5, 6, 7, 8]
An emergency surgical airway can be accomplished by using one of several different methods, including the following:
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Open cricothyroidotomy [9]
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Needle cricothyroidotomy with jet oxygenation
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Percutaneous cricothyroidotomy using the Seldinger technique
Some evidence has supported a trend toward open cricothyroidotomy and away from needle-based approaches, at least in settings where cricothyroidotomy is not frequently performed. [10, 11]
Indications
Adults
A cricothyroidotomy is indicated when a patient’s airway cannot be secured by using nonsurgical methods or when other devices or rescue techniques (ie, intubating laryngeal mask airway, fiberoptic scope, or lighted stylet) have failed or are unavailable. [5] It is also indicated when an airway is required immediately in a patient who is not a candidate for orotracheal or nasotracheal intubation (see the video below)—for instance, in the case of severe facial trauma. [12]
In emergency settings, cricothyroidomy appears to give rise to fewer late complications than tracheostomy; however, current evidence is insufficient to support the use of emergency cricothyroidotomies as long-term airways, and thus, it is advisable to convert these cricothyroidotomies to tracheostomies in a timely manner. [13]
Children
For children younger than 12 years, needle cricothyroidotomy with percutaneous transtracheal (jet) ventilation is the surgical airway of choice. Because a child’s larynx and cricoid cartilage are very soft, mobile, and pliable, a surgical cricothyroidotomy is difficult in this setting.
Contraindications
An absolute contraindication for the creation of an emergency surgical airway is as follows:
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Patient younger than 12 years, unless the child is of teenage or adult size
Relative contraindications for the creation of an emergency surgical airway include the following:
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Airway obstruction distal enough to the cricoid membrane that a cricothyroidotomy would not provide a secure airway with which to ventilate the patient
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Presence of a SHORT neck (ie, Surgery [history of prior neck surgery], Hematoma, Obesity, Radiation [evidence of radiation therapy], or Trauma/burns), making it difficult to locate the patient’s anatomic landmarks or causing an increased risk of further complications
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Tumor, infection, or abscess at the incision site
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Lack of operator expertise
Outcomes
Almost no literature is available comparing surgical cricothyroidotomy with needle cricothyroidotomy. Some comparisons have been made between the use of a cricothyrotome kit and the rapid four-step surgical cricothyroidotomy, but they have demonstrated no significant difference in outcomes or complications.
Kwon et al assessed the incidence and outcomes of cricothyroidotomy in a "cannot intubate, cannot oxygenate" (CICO) situation. [14] A total of 10,187 tracheal intubations were attempted, and 23 patients received cricothyroidotomy (22 in the emergency department [ED] and one in the endoscopy room). The survival rate at hospital discharge was 47.8% (11/23). Aside from cases of cardiac arrest at admission, the survival rate was 62.5% (10/16). Cricothyroidotomy was successful in 17 patients (73.9%), nine (52.9%) of whom survived; it failed in six (26.1%), two (33.3%) of whom survived. After failed cricothyroidotomy, airways were secured via tracheal intubation, nasotracheal intubation, or tracheostomy.
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Fiberoptic-assisted tracheal intubation. Video courtesy of Therese Canares, MD, and Jonathan Valente, MD, Rhode Island Hospital, Brown University.
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Surgical tracheostomy procedure. Video courtesy of Gauri Mankekar, MBBS, MS, PhD.
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Cricothyroidotomy (Seldinger technique). Video courtesy of Therese Canares, MD, and Jonathan Valente, MD, Rhode Island Hospital, Brown University.
