Cricothyroidotomy

April 12, 2022 - read ≈ 5 min

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Content

Authors

Samuel J. Enumah, MD, MBA.

Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, U.S.A.

Authors

Stephanie L. Nitzschke, MD.

Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, U.S.A.

Content

I. Introduction

Cricothyroidotomy is a life-saving procedure that can be performed to establish a definitive airway in situations when oral intubation has failed or a provider is unable to perform the procedure. The cricothyroidotomy does not require many tools, but the procedure does require an understanding of the important landmarks in the neck. Although cricothyroidotomy is not commonly performed, knowledge of this procedure can help health care providers when their patients need an airway.

The aim of the procedure is to establish an entry into the airway through the cricothyroid membrane.

The cricothyroid membrane is bounded by the thyroid cartilage superiorly, the cricoid cartilage inferiorly, and the cricothyroid muscles laterally. A vertical incision on the skin allows the operator to extend the incision superior or inferiorly as necessary if the first incision does not provide adequate visualization. Additionally, the anterior jugular veins course in a vertically oriented fashion just lateral to the midline and a vertical skin incision helps avoid bleeding.

II. Indications/Contraindications

Indications

Massive oral/facial trauma
Oral or facial edema
Inhalation injury caused burn
Difficult anatomy and inability of the operator to intubate
Upper airway obstruction

Contraindications

Absolute contraindications

None in adults

Relative contraindications

Known or suspected tracheal transection
Laryngeal fracture
Tracheal-laryngeal disruption
Children less than ten years old. Preferred procedure is needle cricothyroidotomy with jet ventilation but surgical cricothyroidotomy can be performed if necessary

III. Equipment

Scalpel
10cc syringe
Tracheostomy tube (if Shiley tracheostomy tube is used, do not exceed size 6 (9.4mm outer diameter)).

A 6-0 endotracheal tube can also be used. Larger tubes are associated with increased rates of subglottic stenosis

IV. Preparation

Place patient in the supine position
Use an antiseptic skin preparation agent
The operator should stand on the patient’s right side if the operator is right-handed
Mark the thyroid cartilage (which is superior) and sternal notch (which is inferior)

V. Steps

1) Extend the neck.

2) Palpate and hold the thyroid cartilage with the first and third fingers of the non-dominant hand.

The second finger is used to palpate the cricothyroid membrane.

3) If time permits and patient is conscious, inject local anesthetic to subcutaneous tissue in area of planned incision. If patient is not conscious or there is not time or supplies, proceed to step 4.

4) Make a 4-centimeter vertical skin incision overlying the cricothyroid membrane (Figure 1).

Potential pitfall: In stressful situations, it is easy to confuse the thyroid cartilage for the cricoid cartilage and make the incision too high. Extension of the neck, if possible, helps to avoid this complication
Potential pitfall: It is imperative that you stay in the midline. If your incision is lateral there are critical structures that can cause significant bleeding and make the procedure impossible to perform.
Potential pitfall: The incision could be made too low where you are dissecting through the thyroid/muscle tissue. There is only skin and soft tissue above the cricoid cartilage.

5) Use your finger/hemostat to push through the subcutaneous fat and palpate the cricothyroid membrane.

6) Make a 1-centimeter horizontal incision on the cricothyroid membrane.

7) Use the back end (the blunt end that is not sharp) of the scalpel/hemostat to dilate the opening.

8) Insert the tracheostomy tube (or the endotracheal tube) until the cuff is beyond the cricothyroid membrane (Figure 2).

Potential pitfall: If using an endotracheal tube be careful you do not insert the tube too far or the patient will have the endotracheal tube placed into the right mainstem which will result in elevated peak pressures on the ventilator and loss of left sided breath sounds.

9) Use 10cc of air to inflate the cuff of the tube.

10) Connect the tube to a mechanical ventilator or bag-valve mask machine.

11) Listen for bilateral breath sounds.

12) Confirm end-tidal cardon dioxide using either wave capnography or colorimetric device (if these are available).

13) Secure the tube with sutures or a tracheal tie so that it remains in place.

VI. Complications

False passage
Bleeding
Injury to posterior trachea, esophagus, or thyroid
Tracheoesophageal fistula, subglottic stenosis, and tracheomalacia

False passage: The preferred way to confirm that the tube is in the airway is with end-tidal carbon dioxide monitoring. If a false passage has been created, then continue to oxygenate the patient and re-palpate for the thyroid cartilage and cricoid cartilage to identify the cricothyroid membrane. If needed, an emergent tracheostomy can be performed through the second tracheal ring, which is inferior to the cricoid cartilage.

Bleeding: This can be encountered during an emergent procedure. It is important to remember that the priority is establishing an airway. A vertical skin incision should help one avoid any significant blood vessels. Manual pressure can be used to help slow or stop bleeding during the procedure.

Injury to surrounding structures: When making the horizontal incision on the cricothyroid membrane, avoid allowing your scalpel to travel too far posteriorly as this may lead to injury of the posterior trachea or the esophagus. These injuries can lead to complications including a tracheoesophageal fistula.

Long-term use of a cricothyroidotomy can lead to stenosis. Patients who undergo this procedure should subsequently undergo a formal tracheostomy in a non-emergent setting in the next few days after the cricothyroidotomy is performed.

References

Advanced Surgical Skills for Exposure in Trauma (ASSET), 2^nd edition: Chapter 6, Surgical Airway: Cricothyroidotomy. The Committee on Trauma. American College of Surgeons. 2020.
Bernstein ML, Wang SC. Chapter 45. Tracheostomy and Emergency Cricothyroidotomy. In: Minter RM, Doherty GM. Eds. Current Procedures: Surgery. Ann Arbor, Michigan. McGraw Hill; 2010.
Nickson, Chris. Surgical Cricothyroidotomy. Life in the Fastlane. Available from: https://litfl.com/surgical-cricothyroidotomy. Accessed 10 March 2022.