Cricothyroidotomy (Cricothyrotomy)

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.

Open cricothyroidotomy

Steps in the procedure are as follows:

Assemble and prepare equipment
Position the patient supine, with the neck in a neutral position
Clean the patient’s neck in a sterile fashion using antiseptic swabs
Anesthetize the area locally, if time allows
Locate the cricothyroid membrane anteriorly between the thyroid and the cricoid cartilage
Stabilize the trachea with the left hand until the trachea is intubated
Make a 2- to 3-cm midline vertical incision through the skin from the caudal end of the thyroid cartilage to the cephalic end of the cricoid cartilage
Make a 1- to 2-cm transverse incision through the cricothyroid membrane
Insert the scalpel handle into the incision and rotate 90° (a hemostat may also be used to open the airway)
Insert a tracheal hook into the opening, hooking the caudal end of the opening, and lift, allowing for passage of an appropriately sized cuffed endotracheal or tracheostomy tube (usually No. 5 or No. 6), directing the tube distally.
One alternative to the preceding step is to insert the tube through the opening produced by the opened hemostat; a second alternative is to hold the handle of the scalpel straight down in the opening, slide the handle cephalically, insert the tube straight down along the handle until it hits the back of the trachea, angle the tube caudally, and advance the tube
Inflate the cuff; observe and check for chest rise
Secure the airway
Take care not to cut the thyroid or the cricoid cartilage

A surgical tracheostomy is depicted in the video below.

Surgical tracheostomy procedure. Video courtesy of Gauri Mankekar, MBBS, MS, PhD.

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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]

Needle cricothyroidotomy

Steps in the procedure are as follows:

Follow the first four steps listed above for surgical cricothyroidotomy
Assemble a 12- or 14-gauge (16- or 18-gauge in children) 8.5-cm over-the-needle catheter to a 10-mL syringe
Locate the cricothyroid membrane anteriorly between the thyroid and the cricoid cartilage
Stabilize the trachea with the thumb and forefinger of one hand
Using the other hand, puncture the skin in the midline with the needle over the cricothyroid membrane; a small incision with a No. 11 blade may be made first to facilitate passage of the needle
Direct the needle at a 45° angle caudally while applying negative pressure to the syringe
Maintain needle aspiration as the needle is inserted through the lower half of the cricothyroid membrane; aspiration of air signifies entry into the tracheal lumen
Remove the syringe and needle while advancing the catheter to the hub
Attach the oxygen catheter, and secure the airway

Percutaneous cricothyroidotomy using Seldinger technique

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.)

Cricothyroidotomy (Seldinger technique). Video courtesy of Therese Canares, MD, and Jonathan Valente, MD, Rhode Island Hospital, Brown University.

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Steps in the procedure are as follows:

Follow the first four steps listed above for surgical cricothyroidotomy
Locate the cricothyroid membrane anteriorly between the thyroid and the cricoid cartilage
Stabilize the trachea with the thumb and forefinger of one hand
Using the other hand, puncture the skin in the midline with the finder needle with attached syringe over the cricothyroid membrane; a small incision with a No. 11 blade may be made first to facilitate passage of the needle
Direct the needle at a 45° angle caudally while applying negative pressure to the syringe
Maintain needle aspiration as the needle is inserted through the lower half of the cricothyroid membrane; aspiration of air signifies entry into the tracheal lumen
Remove the syringe, leaving the needle in place, and advance the guide wire through the needle
A small incision with a No.11 blade may be needed to enlarge the hole before insertion of the dilator; it is recommended to make this incision before removing the needle so as not to cut the guide wire accidentally
Insert the dilator–airway tube combination over the guide wire; once the airway device is in place, remove the dilator and the guide wire
Attach the oxygen catheter, and secure the airway

Percutaneous transtracheal ventilation

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

Complications associated with open cricothyroidotomy include the following:

Aspiration
Creation of false passage into the tissue
Subglottic stenosis
Laryngeal stenosis
Hemorrhage/hematoma
Esophageal/tracheal laceration
Mediastinal emphysema ^[15]
Vocal cord injury

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:

Inadequate ventilation/hypoxia
Aspiration (blood)
Esophageal laceration
Posterior tracheal wall perforation
Subcutaneous emphysema
Thyroid perforation
Hypercarbia

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:

Pulmonary rupture
Pneumothorax/ tension pneumothorax

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Media Gallery

Fiberoptic-assisted tracheal intubation. Video courtesy of Therese Canares, MD, and Jonathan Valente, MD, Rhode Island Hospital, Brown University.
Surgical tracheostomy procedure. Video courtesy of Gauri Mankekar, MBBS, MS, PhD.
Cricothyroidotomy (Seldinger technique). Video courtesy of Therese Canares, MD, and Jonathan Valente, MD, Rhode Island Hospital, Brown University.