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Establishment of an airway is of prime importance to survival. The most predictive factor of survival from cardiac arrest is establishment of an airway.1 Unfortunately, the Emergency Physician is occasionally confronted with an airway that is extremely difficult or even impossible to obtain by endotracheal intubation. Between 1% and 4% of all emergent airways require a cricothyroidotomy.2–5 Up to 7% of trauma patients who present in cardiopulmonary arrest will require a cricothyroidotomy.3
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The technique of cricothyroidotomy has been documented in use since the early 1900s. In 1921, Chevalier Jackson condemned its use because of fears of subglottic stenosis.6,7 Jackson's technique involved incising the cricoid cartilage, which led to the subglottic stenosis. The technique was popularized again in 1966 by Brantigan and Grow, but it was considered primarily an elective procedure.6,7 Cricothyroidotomy has since evolved into the surgical airway of choice for emergent situations in which other intubation methods have failed or are contraindicated.2,8 The Emergency Physician using rapid sequence induction to intubate patients should be knowledgeable and skilled in performing a cricothyroidotomy.3 The success rate of a cricothyroidotomy ranges from 96% to 100%.4,9
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A cricothyroidotomy has numerous advantages over a tracheostomy.6,10,11 A cricothyroidotomy is easier, faster, and safer to perform. It can be performed in less than 2 minutes. It can be 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 superficial, easily seen, and easily palpated. The procedure does not require a deep dissection, as the structures are located subcutaneously. The cricothyroid membrane is not covered by any structures that would interfere with the procedure. Because the cricothyroid membrane is in the upper part of the neck, there is less chance of injuring the esophagus. A cricothyroidotomy can be performed with the patient's neck in a neutral position. This is especially important in those with potential cervical spine injuries. The procedure has fewer associated complications than a tracheostomy. Although not a concern when securing an airway, the skin incision will heal with a smaller and less noticeable scar.
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The cricothyroid membrane is located between the thyroid cartilage superiorly and the cricoid cartilage inferiorly (Figure 25-1). The cricothyroid membrane must be identified by palpation of the surrounding cartilaginous structures. Using the nondominant hand, place the thumb on one side of the thyroid cartilage and the middle finger on the other side (Figure 25-2). Palpate the laryngeal prominence (Adam's apple) with the index finger. It is important to locate the hyoid bone superiorly to ensure that the incision is not superior to the vocal cords. Moving inferiorly, the index finger will fall into a hollow, which is the location of the cricothyroid membrane. The next structure palpated is the firm cartilaginous ring ...