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:
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]
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]
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.
An absolute contraindication for the creation of an emergency surgical airway is as follows:
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:
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.
Equipment for open cricothyroidotomy (cricothyrotomy) includes the following:
Equipment for needle cricothyroidotomy includes the following:
Equipment for percutaneous cricothyroidotomy using the Seldinger technique includes the following:
If time permits and the patient is not unresponsive, injection of the skin and subcutaneous tissue over the cricothyroid membrane with 1% lidocaine solution provides adequate anesthesia.
Position the patient supine, with the neck in a neutral position.
An emergency surgical airway can be created by means of several different methods, including open cricothyroidotomy (cricothyrotomy), needle cricothyroidotomy with jet oxygenation, and percutaneous cricothyroidotomy using the Seldinger technique.
Steps in the procedure are as follows:
A surgical tracheostomy is depicted in the video below.
A randomized controlled study comparing surgical cricothyroidotomy with percutaneous Seldinger-based cricothyroidotomy as performed 21 emergency physicians and nine emergency medicine trainees found that the surgical procedure could be performed more quickly and comfortably and was the preferred technique in this study group.[11]
Steps in the procedure are as follows:
The cricothyrotome kit for this procedure is used in much the same way as in a needle cricothyroidotomy but relies on the Seldinger technique. These kits are available in some hospitals and should be used only in patients older than 12 years. (See the video below.)
Steps in the procedure are as follows:
Connect the cannula to oxygen at 15 L/min (40-50 psi) using a Y-connector or through a hole cut in the side of a nasal cannula. Intermittent ventilation (1 s on, 4 s off) can be achieved by placing a thumb over the open end of the Y-connector or cannula.
This method can be used for about 30-40 minutes. However, it causes an accumulation of carbon dioxide and therefore must be used sparingly in patients who have sustained head trauma.
Complications associated with open cricothyroidotomy include the following:
A systematic review by DeVore et al found that the most frequent early complication after emergency surgical cricothyroidotomy was failure to obtain an airway; the most common long-term complication was airway stenosis.[16] A retrospective single-institution case series by Moroco et al found improper placement to be the most common complication.[17]
Complications associated with needle cricothyroidotomy include the following:
Ultrasonographic (US) guidance may reduce the incidence of airway damage.[2] Whether airway injury is present after the procedure may be determined by means of fiberoptic bronchoscopy, radiography, or computed tomography (CT).[18]
Complications associated with percutaneous transtracheal ventilation include the following: