Cricothyrotomy

Cricothyrotomy

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A cricothyrotomy (also called cric, crike, thyrocricotomy, cricothyroidotomy, inferior laryngotomy, intercricothyrotomy, coniotomy or emergency airway puncture) is an incision made through the skin and cricothyroid membrane to establish a patent airway during certain life-threatening situations, such as airway obstruction by a foreign body, angioedema, or massive facial trauma. Cricothyrotomy is nearly always performed as a last resort in cases where orotracheal and nasotracheal intubation is impossible or contraindicated. Cricothyrotomy is easier and quicker to perform than tracheotomy, does not require manipulation of the cervical spine, and is associated with fewer complications. However, while cricothyrotomy may be life-saving in extreme circumstances, this technique is only intended to be a temporizing measure until a definitive airway can be established.

Indications

A cricothyrotomy is often used as an airway of last resort given the numerous other airway options available including standard tracheal intubation and rapid sequence induction which are the common means of establishing an airway in an emergency scenario. Cricothyrotomies account for approximately 1% of all emergency department intubations, and is used mostly in persons who have experienced a traumatic injury.

Some general indications for this procedure include:

  • Inability to intubate
  • Inability to ventilate
  • Inability to maintain SpO2 >90%
  • Severe traumatic injury that prevents oral or nasal tracheal intubation

Contraindications

  • Inability to identify landmarks (cricothyroid membrane)
  • Underlying anatomical abnormality such as a tumor or severe goiter
  • Tracheal transection
  • Acute laryngeal disease due to infection or trauma
  • Small children under 12 years old (a 10–14 gauge catheter over the needle may be used)
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Procedure

The procedure was first described in 1805 by Félix Vicq-d’Azyr, a French surgeon and anatomist. A cricothyrotomy is generally performed by making a vertical incision on the skin of the throat just below the laryngeal prominence (Adam’s apple), then making another transverse incision in the cricothyroid membrane which lies deep to this point. A tracheostomy tube or endotracheal tube with a 6 or 7 mm internal diameter is then inserted, the cuff is inflated, and the tube is secured. The person performing the procedure might utilize a bougie device, a semi-rigid, straight piece of plastic with a one-inch tip at a 30-degree angle, to provide rigidity to the tube and assist with guiding its placement. Confirmation of placement is assessed by bilateral ausculation of the lungs and observation of the rise and fall of the chest. Alternatively, bedside ultrasound has been used increasingly to guide the procedure and confirm the placement of the tracheal tube. It may especially be helpful in situations where a neck collar is placed.

Needle cricothyrotomy

A needle cricothyrotomy is similar, but instead of making a scalpel incision, a large over-the-needle catheter is inserted (10- to 14-gauge). This is considerably simpler, particularly if using specially designed kits. This technique provides very limited airflow. The delivery of oxygen to the lungs through an over-the-needle catheter inserted through the skin into the trachea using a high pressure gas source is considered a form of conventional ventilation called percutaneous transtracheal ventilation (PTV).

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