Cricothyroidotomy

Cricothyroidotomy

David Ray Velez, MD

Table of Contents

General Considerations
Standard Technique
Rapid Four-Step Technique (RFST)
Percutaneous (Seldinger) Technique

General Considerations

Definition: An Emergent Surgical Airway Through an Incision in the Cricothyroid Membrane

Also Known as “Cricothyrotomy” or “Cric”

Use

  • Cricothyroidotomy is the Most Rapid Surgical Approach to Secure the Airway
    • Formal Tracheostomy is Too Slow for the Emergent Setting
  • Cricothyroidotomy is Too Superior in the Neck to Allow Long-Term Airway Control – High Risk for Tracheal Stenosis
  • Used as a Temporary Measure Until a Formal Tracheostomy Can Be Performed in a Controlled Setting
    • Generally Prefer to Formalize within 24 Hours to Avoid Complications

Indications

  • Cricothyroidotomy is Indicated Emergently if Unable to Intubate or Ventilate
  • Many Follow a “Three-Strikes” Rule: If Unable to Secure Endotracheal Intubation After Three Attempts by the Most-Competent Provider, Secure the Airway Through Cricothyroidotomy
  • Common Causes:
    • Maxillofacial Trauma
    • Neck Trauma
    • Severe Inhalational Injury with Airway Edema
    • Anaphylaxis
    • Facial/Oropharyngeal Swelling/Edema
    • Airway Obstruction by Foreign Body (Food/Teeth)
    • Congenital Deformity

Contraindications

  • The Only Contraindication is Young Age (< 10-12 Years Old)

Equipment

  • Minimum Equipment:
    • Scalpel
    • Finger
    • Tracheostomy or Endotracheal Tube (6.0 mm Generally Preferred)
  • Additional Equipment:
    • Bougie
    • Trousseau Dilator
    • Surgical Hook

Sterile Preparation May Not Be Possible in a True Emergency

There Will Be Significant Bleeding – Ignore Initially and Secure the Airway Before Managing Bleeding

Indicators of Difficult Cricothyroidotomy: SHORT Mnemonic

  • Surgery
  • Hematoma or Abscess
  • Obesity
  • Radiation Distortion or Deformity
  • Tumor

Complications

  • Failure to Achieve Access
  • Death
  • Bleeding
  • Infection
  • Pneumothorax
  • Laryngeal Injury
  • Cartilage Fracture (Thyroid or Cricoid Cartilage)
    • Can Cause Vocal Cord Dysfunction/Paralysis After Decannulation
  • Esophageal Injury and Tracheoesophageal Fistula
  • Tracheal Stenosis

Standard Technique

Palpate and Identify Anatomical Landmarks

  • Thyroid Cartilage
  • Cricoid Cartilage
  • Cricothyroid Membrane

Skin Incision (Vertical)

  • Vertical Midline Incision is Generally Preferred to Limit Bleeding
    • Some Prefer Horizontal Incisions
  • Length: 3-5 cm
  • Use Hands to Stabilize the Trachea if Able

Palpate and Incise the Cricothyroid Membrane (Horizontal)

  • Between the Thyroid and Cricoid Cartilages
  • May Require Some Dissection to Identify if Deep (Obese, Short Neck, Swelling)

Access the Trachea

  • Options:
    • Finger
    • Trousseau Dilator
    • Bougie
    • Back of a Scalpel – Take Extreme Caution Not to Cut Yourself in the Moment
  • Can Consider Placing Bougie Along a Finger into the Trachea to Guide the Tracheostomy Tube

Insert Tracheostomy Tube

  • Generally Use a 6.0 mm Tube
  • Can Insert a Regular Endotracheal Tube if a Tracheostomy Tube is Not Immediately Available

Cricothyroidotomy: (A) Vertical Skin Incision, (B) Horizontal Incision Through the Cricothyroid Membrane

Rapid Four-Step Technique (RFST)

Step 1: Palpate the Cricothyroid Membrane

Step 2: Stab Incision Through Both the Skin and Cricothyroid Membrane

Step 3: Use Hook to Retract the Larynx Caudally

Step 4: Insert the Tracheostomy Tube

Percutaneous (Seldinger) Technique

Uses a Modified Seldinger Approach Via Needle and Guidewire

Palpate and Identify Anatomical Landmarks

  • Thyroid Cartilage
  • Cricoid Cartilage
  • Cricothyroid Membrane

Needle

  • Use a Hollow Introducer Needle to Puncture Through the Skin and Cricothyroid Membrane into the Trachea
  • Applying Negative Pressure to the Syringe While Placing, Bubbles Indicate Tracheal Access

Guidewire

  • Pass a Guidewire Through the Needle
  • Withdraw the Needle Over the Guidewire, Leaving the Guidewire in the Trachea
  • Always Maintain Control of the Guidewire During Placement

Dilate the Tract

  • Make a Small Skin Incision at the Entry Site
  • Pass a Dilator Over the Guidewire to Dilate the Tract

Place the Tracheostomy Tube

  • Pass the Tracheostomy Tube Over the Guidewire
  • Withdraw the Guidewire
  • Begin Ventilating Through the Tracheostomy Tube