Establishment of an airway is imperative to patient survival.1 The most predictive factor of survival from cardiac arrest is establishment of an airway.2 The Emergency Physician is occasionally confronted with an airway that is extremely difficult or even impossible to obtain by endotracheal intubation.3 Up to 4% of all emergent airways require a cricothyroidotomy.4-8 Up to 7% of trauma patients who present in cardiopulmonary arrest will require a cricothyroidotomy.6
The technique of cricothyroidotomy has been documented in use since the early 1900s. Chevalier Jackson condemned its use in 1921 because of fears of subglottic stenosis.9,10 Jackson’s technique involved incising the cricoid cartilage, which was responsible for the resulting subglottic stenosis. The technique was popularized again in 1966 by Brantigan and Grow, but it was considered primarily an elective procedure.9,10 Cricothyroidotomy has since evolved into the surgical airway of choice for emergent situations in which other intubation methods have failed or are contraindicated.5,11 The Emergency Physician using rapid sequence induction to intubate patients must be knowledgeable and skilled in performing a cricothyroidotomy.6 The success rate of a cricothyroidotomy ranges from 96% to 100%.7,12
The most difficult part of performing a cricothyroidotomy is deciding to do it. The Emergency Physician often continues to attempt intubation in hopes of gaining the airway. The decision to perform a cricothyroidotomy is often made after the patient is hypoxic and cannot be intubated, oxygenated, or ventilated. There are often multiple intubation attempts before the decision is made to perform a cricothyroidotomy. Quickly determine if intubation is unsuccessful and prevent delaying the cricothyroidotomy. Follow a difficult airway algorithm.
A cricothyroidotomy has numerous advantages over a tracheostomy.9,13,14 A cricothyroidotomy is easier, faster, and safer to perform. It can be performed in less than 2 minutes and performed by those with little or no surgical training. It does not require the support of an Operating Room and a large amount of equipment. The anatomic landmarks are easily palpated, easily seen, and superficial. The procedure does not require a deep dissection as the structures are located superficially. The cricothyroid membrane is not covered by any structures that would interfere with the procedure. There is a minimal chance of injuring the esophagus because the cricothyroid membrane is in the anterior part of the neck. A cricothyroidotomy can be performed with the patient’s neck in a neutral position rather than the extended position. This is especially important in those with potential cervical spine injuries. The procedure has fewer associated complications than a tracheostomy. The skin incision will heal with a smaller and less noticeable scar, although this is not a concern when securing an airway emergently.
ANATOMY AND PATHOPHYSIOLOGY
The cricothyroid membrane is located between the thyroid cartilage superiorly and the cricoid cartilage inferiorly ...