Chapter 25. Cricothyroidotomy

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

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

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.

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 of the cricoid cartilage, followed by the tracheal rings.

The cricothyroid membrane itself is a thin membrane measuring 2 to 3 cm in width and only 9 to 10 mm in height.8,11 It is located approximately 1 cm below the true vocal cords.11 There is relatively little subcutaneous tissue overlying the cricothyroid membrane. There are few to no vascular structures overlying the cricothyroid membrane. The anterior cricothyroid arteries travel from lateral to medial over the superior border of the cricothyroid membrane. The anterior jugular veins may lie immediately superior and lateral to the cricothyroid membrane. Farther lateral and posterior are the great vessels of the neck. Posterior to the larynx and trachea is the esophagus. It is therefore important not to make the incision too deep, thus risking an esophageal intubation or injury.

The most frequent indication for an emergent or urgent surgical airway is the inability to intubate endotracheally with less invasive techniques. These less invasive techniques may have failed or been contraindicated.10 Attempts at orotracheal or nasotracheal intubation should be made prior to attempts at creating a surgical airway.4,8 A common reason for the failure of orotracheal intubation is not using rapid sequence induction and the patient's clenched teeth precluding intubation.9 Other common reasons for failure to establish endotracheal intubation include severe neck or facial injury resulting in distortion of the normal anatomy, edema, masseter spasm, laryngospasm, cervical spine injury, deformities of the mouth and/or pharynx, upper airway hemorrhage, large amounts of vomitus in the oropharynx, and upper airway obstruction.8,9,11 Although endotracheal intubation should be attempted first, it is prudent to have the surgical airway supplies nearby if it is suspected that the patient may have a difficult airway. The old saying among Anesthesiologists “A surgical airway is better than a deceased patient with a good-looking neck” holds quite true.

Needle cricothyroidotomy is the emergent “surgical” airway of choice in a patient younger than 8 to 10 years of age.11,12 In young children, the cricothyroid membrane as well as the surrounding structures are much smaller and more difficult to access. It is easier to injure one of the cervical vessels or the esophagus when a standard cricothyroidotomy is performed in a child. Subglottic stenosis is a common late complication following cricothyroidotomy in children.12 A needle cricothyroidotomy is a safer alternative and allows for adequate oxygenation and ventilation until a formal tracheostomy or other method of endotracheal intubation can be performed. Unfortunately, the small caliber of the catheter may not provide adequate oxygenation and ventilation in an adult.

There are a few absolute contraindications to performing a cricothyroidotomy. The most important is if the patient can be endotracheally intubated by less invasive methods. Partial or complete transection of the airway is a contraindication to a cricothyroidotomy. In these cases, a tracheostomy is the preferred method to secure the airway. Finally, this procedure should not be performed in cases of significant injury or fracture of the cricoid cartilage, larynx, and/or thyroid cartilage.

There are some situations where the performance of a cricothyroidotomy may be less desirable. The presence of laryngeal pathology (e.g., tumor, fracture) may preclude the performance of a cricothyroidotomy and necessitate a high tracheostomy.11,13 If a patient has been previously intubated endotracheally for a prolonged period, there is a higher incidence of long-term complications following a cricothyroidotomy.13 While this does not prevent the performance of a cricothyroidotomy, one should consider an early revision to a tracheostomy to minimize these complications. Other relative contraindications to performing a cricothyroidotomy are the presence of a coagulopathy, massive neck swelling, or a hematoma in the neck; all of which increase the risk of bleeding and distortion of the anatomy. Finally, unfamiliarity with the technique may lead to increased complications.11

General Supplies

• Sterile gloves, gowns, and drapes
• Face mask and eye protection
• 1% lidocaine local anesthetic solution
• Syringes, 5 and 10 mL
• Needles, 18 to 27 gauge
• Bag-valve-mask device
• Oxygen source and tubing
• Suction source, tubing, and catheter
• Pulse oximeter
• Noninvasive blood pressure cuff
• Cardiac monitor
• End-tidal CO2 monitor

Surgical Cricothyroidotomy

• Povidone iodine or chlorhexidine solution
• #11 scalpel blade on a handle
• Trousseau tracheal dilator or curved 6 in hemostat
• Tracheal hook
• Hemostats, 4 small
• Needle driver
• Suture scissors
• Tracheostomy tubes, sizes #4 and #6
• Endotracheal tubes, various sizes
• Tracheostomy tape (twill tape)
• 3-0 sutures for hemostasis (e.g., Dexon, Vicryl, or chromic)
• 3-0 nylon sutures for skin closure
• 1 in tape (or a commercially available endotracheal tube holder)
• Gauze 4 × 4 squares
• Iodoform gauze ribbon
• Percutaneous cricothyroidotomy kit, adult and pediatric sizes

Needle Cricothyroidotomy

• Povidone iodine or chlorhexidine solution
• 14 gauge catheter-over-the-needle (angiocatheter), 2 in long
• 5 mL syringe
• Tape
• Percutaneous transtracheal jet ventilator (Chapter 24)

The equipment should be prepackaged in a sterile tray that is readily accessible. Some institutions maintain separate cricothyroidotomy and tracheostomy trays. Others have one tray that contains the equipment necessary to perform both procedures. If a cricothyroidotomy tray is not immediately available, a thoracotomy tray usually contains all the required equipment to perform this procedure.

Should the Emergency Department stock surgical cricothyroidotomy kits, percutaneous cricothyroidotomy kits, or both? The answer to this will depend on Emergency Physician preference, hospital stores, and available budget. The Melker Universal Emergency Cricothyroidotomy Catheter Set (Cook Inc., Bloomington, IN) may resolve this issue for some Emergency Departments. This single-use, disposable kit contains all the equipment required to perform both types of cricothyroidotomies. The convenience of having all the required equipment readily available in one kit can clearly justify the cost. Unfortunately, this kit is only available in one adult size.

A cricothyroidotomy is most commonly an emergent procedure. There is little if any time to explain this to the patient and obtain their consent. If there is sufficient probability that an awake and stable patient will require a surgical airway, informed consent may be obtained.

The patient should be appropriately monitored with electrocardiography (ECG), end-tidal CO2 monitoring, noninvasive blood pressure cuff, and pulse oximetry. The patient preparation is exactly the same as that for orotracheal intubation. As for any situation where airway manipulation is to occur and the patient's protective airway reflexes are blunted or ablated, a fully functioning suction apparatus with a variety of catheters must be immediately available.

Place the patient supine with their head in a neutral position. Place a rolled towel under the patient's upper shoulders and neck if no contraindications exist (Figure 25-3). This position offers excellent exposure, stabilizes and prevents the airway structures from moving, and lengthens the cricothyroid membrane. While it is not impossible to perform a cricothyroidotomy with a cervical collar on the patient, it is very difficult. If the patient is at risk for a cervical spine injury, it is preferable to remove the collar while an assistant maintains in-line stabilization of the head and neck in a neutral position. An additional assistant should maintain the airway and provide ventilatory support with a bag-valve-mask device.

In the ideal situation, the skin of the anterior neck should be prepped with povidone iodine or chlorhexidine solution and sterile drapes placed to isolate a surgical field. The Emergency Physician performing the procedure should be clad in a mask, a sterile gown, and gloves. The circumstances in which the procedure is usually performed often require that the airway be obtained rapidly. In these cases, a quick spray of povidone iodine or chlorhexidine and sterile gloves will suffice.

During the performance of this procedure, one or two assistants should be maintaining the airway by providing ventilation and oxygenation with a bag-valve-mask device or a supraglottic airway device. The right-handed Emergency Physician should be standing at the patient's right side. The position is reversed for the left-handed Emergency Physician.

Stabilize the large thyroid cartilage in place with the thumb and middle finger of the nondominant hand (Figure 25-2).8,14 The immobilization of the larynx cannot be overemphasized. If the larynx is not secure and thus the landmarks are lost, the procedure will fail. Identify the anatomic landmarks necessary to perform this procedure. This is critical to the performance of a cricothyroidotomy. Place the index finger over the laryngeal prominence (Adam's apple). Move the index finger inferiorly to identify the cricothyroid membrane, cricoid cartilage, and tracheal rings (in this order). Move the index finger superiorly until it falls back into the cricothyroid membrane. Leave the index finger over the cricothyroid membrane. Using the index finger of the dominant hand, confirm that the nondominant index finger is situated over the cricothyroid membrane. If the patient is awake and stable, infiltrate the area of the incision with local anesthetic solution after the landmarks are identified.

Traditional Technique

Make a 2 to 3 cm transverse incision, centered in the midline, through the skin and subcutaneous tissue (Figures 25-4 & 25-5A). Continue the incision through the cricothyroid membrane. As one gains skill with this procedure, all layers may be incised simultaneously with one incision. The beginner should proceed with some caution because there is a small risk of incising through the posterior wall of the airway.8,11 The incision should be no longer than 3 cm or 1.5 cm on either side of the midline, as this represents the width of the cricothyroid membrane.7,14 Longer incisions risk injury to the anterior jugular veins that lie just lateral to the thyroid cartilage.11

Longitudinal incisions in the midline are not recommended. They take longer to perform and require repositioning after the skin incision. The primary indication for a longitudinal skin incision is in the patient with a suspected laryngeal injury and distortion of the anatomic landmarks.11 In these cases, the longitudinal incision permits the extension of the incision inferiorly in order to perform a high tracheostomy.

Once the cricothyroid membrane has been incised and the airway entered, a hiss of air with ventilations and bubbling should be noted through the wound. This is true if the patient is ventilating spontaneously or with the assistance of a bag-valve-mask device. Do not remove the scalpel. Insert the tracheal hook along the scalpel and grasp the inferior border of the thyroid cartilage (Figure 25-5B). Elevate the tracheal hook to retract the thyroid cartilage anteriorly and superiorly.4,5 The scalpel may now be removed. The incision site must be expanded to accommodate the passage of an endotracheal tube or a tracheostomy tube. While controlling the airway with the tracheal hook, insert the jaws of a Trousseau dilator (or 6 in hemostat) through the cricothyroid membrane in the midsagittal plane (Figure 25-5C). Open the jaws of the instrument to dilate the opening in the sagittal plane.4,5,7,8 Rotate the dilator 90° within the incision. Open the jaws of the dilator to dilate the incision in the transverse plane. Remove the dilator while continuing to maintain control of the airway with the tracheal hook.

Select a tracheostomy tube that is of an appropriate size for the patient. Instruct an assistant to lubricate the obturator and outer cannula, then insert the obturator into the outer cannula. While maintaining control of the airway with the tracheal hook, insert the tracheostomy tube perpendicularly (90°) to the skin (Figure 25-5D). Continue to advance the tracheostomy tube with a semicircular motion and inferiorly until the flange is against the skin. The tracheostomy tube should pass with minimal difficulty. Remove the tracheal hook. Securely hold the outer cannula. Remove the obturator, insert the inner cannula, inflate the cuff of the tracheostomy tube, connect the bag-valve device, and ventilate the patient.4 Confirm the intratracheal position of the tube by auscultating bilateral breath sounds, noting the absence of breath sounds over the stomach, and a colorimetric or quantitative end-tidal CO2 assessment.

Alternative Surgical Technique

An alternative surgical approach to a cricothyroidotomy was first developed by Oppenheimer.17 It is simpler, more rapid, and easier to perform than the traditional technique described above (Figures 25-6 & 25-7). The technique has been modified from the original description.18

Clean, prepare, and drape the neck as mentioned previously. Position the nondominant hand with the thumb on one side of the thyroid cartilage and the middle finger on the other side (Figures 25-6A & 25-7A). Identify the anatomic landmarks as described previously. Leave the nondominant index finger over the cricothyroid membrane. If the patient is awake, infiltrate local anesthetic solution subcutaneously over the cricothyroid membrane.

Guide a #11 surgical blade along the nondominant index finger and into the cricothyroid membrane using a stab incision (Figures 25-6A, B, & 25-7B). Do not insert the scalpel blade more than 1.5 to 2.0 cm to prevent it from injuring the esophagus. It is recommended to hold the scalpel just above the blade with the thumb and index finger to prevent it from plunging too deep.18 Air or bubbles from the incision signify that the tip of the scalpel blade is inside the trachea. Do not remove the scalpel blade. Move it laterally 0.75 cm to extend the incision (Figures 25-6C & 25-7C). Rotate the scalpel blade 180° and extend the incision 0.75 cm in the opposite direction (Figures 25-6D & 25-7D). Do not remove the scalpel blade. Removing the scalpel from the incision will result in losing the landmarks and the location of the incision through the cricothyroid membrane.

With the scalpel blade in place, insert a tracheal hook into the midline of the incision (Figures 25-6E & 25-7E). Grasp the inferior border of the thyroid cartilage with the tracheal hook. Lift the tracheal hook upward and superiorly to elevate and control the airway (Figures 25-6F & 25-7F). Remove the scalpel from the incision only after the airway is controlled with the tracheal hook.

The incision site must be expanded to accommodate the passage of an endotracheal tube or a tracheostomy tube. While controlling the airway with the tracheal hook, insert the jaws of a Trousseau dilator (or 6 in hemostat) through the cricothyroid membrane in the midsagittal plane (Figures 25-6G & 25-7G). Open the jaws of the instrument to dilate the opening in the sagittal plane (Figure 25-7H). Rotate the dilator 90° within the incision (Figure 25-7I). Open the jaws of the dilator to dilate the incision in the transverse plane (Figure 25-7J). Insert an endotracheal tube or a tracheostomy tube through the incision and into the trachea (Figures 25-6H & 25-7K). Hold the tube securely against the skin and remove the tracheal hook. The remainder of the procedure is as described previously.

Patients with Massive Neck Swelling

Patients may present with massive neck swelling secondary to hemorrhage, hematoma, edema, or subcutaneous emphysema after trauma.19 These patients often have no palpable anatomic landmarks in the neck, making it difficult to create a surgical airway. The traditional surgical methods used to perform a cricothyroidotomy are not usable due to hemorrhage and difficulty in identifying the anatomic landmarks. However, a technique has been developed to perform a cricothyroidotomy in these patients.20–22

To use this technique, the location of the hyoid bone must be determined (Figure 25-8A). A piece of suture, string, or tracheal tie is required. Place one end of the suture at the angle of the patient's mandible. Stretch the suture along the mandible and note where it contacts the tip of the chin (Figure 25-8A, line 1). Cut the suture at the point where it contacts the tip of the chin. Fold the suture in half. Place one end of the folded suture on the tip of the chin. Pull the other end of the folded suture tight to make a 90° angle to line 1 (Figure 25-8A, line 2). An imaginary line should be drawn from the free end of the folded suture to the angle of the patient's mandible (Figure 25-8A, line 3). This third line is the line used to identify the hyoid bone.

Insert a #11 scalpel blade through the midline of the neck in an upward and posterior direction along line 3 (Figure 25-8B). Advance the scalpel blade until it meets resistance as it contacts the hyoid bone. Alternatively, a spinal needle can be inserted along line 3 until it contacts the hyoid bone (Figure 25-8C). Then, insert the #11 scalpel along the track of the spinal needle until the hyoid bone is also contacted. Do not remove the scalpel. Insert a tracheal hook along the scalpel blade until the hyoid bone is contacted. Move the tip of the tracheal hook under the hyoid bone (Figure 25-8D). Lift the tracheal hook anteriorly and superiorly to elevate and control the airway (Figure 25-8D). Do not release the hold of the tracheal hook on the hyoid bone. Remove the scalpel from the incision.

Make an incision inferiorly and in the midline starting at the site the tracheal hook exits the skin. The incision should extend directly inferiorly without regard to the anatomy of the neck. Do not release the tension on the tracheal hook. Identify the cricothyroid membrane. Make a transverse incision through the cricothyroid membrane. Dilate the opening and insert a tracheostomy tube or an endotracheal tube into the trachea as described previously.

Seldinger Technique

A percutaneous cricothyroidotomy kit is available from several manufacturers. One of the more commonly used kits is the Melker Percutaneous Cricothyrotomy Set (Cook Inc., Bloomington, IN). It is a self-contained kit that may be used in the prehospital setting, Emergency Department, or Operating Room. It contains percutaneous needles, a catheter-over-the-needle, a syringe, a #15 scalpel blade, adult and pediatric airway catheters, dilators that fit inside the airway catheters, a 30 cm flexible guidewire, and a tracheal tie (Figure 25-9). The dilator was developed to fit inside the airway catheter (Figure 25-10). The dilator and airway catheter are inserted as a unit during the procedure.

The percutaneous cricothyroidotomy kit can be used to establish an airway using a modification of the Seldinger technique.23–25 This technique can be used to establish an airway in about the time it takes to create a surgical cricothyroidotomy.23,24 For those with little surgical experience, a percutaneous cricothyroidotomy is a simpler and quicker technique with which to establish an airway than traditional surgical methods. The technique is quite similar to inserting a central venous line.28

Clean, prep, drape, and anesthetize the patient's neck as mentioned previously. Lubricate the dilator liberally and insert it through the airway catheter (Figure 25-10). Lubricate the airway catheter and dilator after it has been assembled into a unit. Stabilize the trachea with the nondominant hand and identify the landmarks as previously described. Leave the nondominant index finger over the center of the cricothyroid membrane.

Make a stab incision just through the skin over the center of the cricothyroid membrane with the #11 scalpel blade (Figure 25-11A). Insert the catheter-over-the-needle attached to a 5 mL syringe containing saline through the skin incision and aimed inferiorly (Figure 25-11B). Insert and advance the catheter-over-the-needle at a 30° to 45° angle to the skin (Figure 25-11B). Advance the catheter-over-the-needle while applying negative pressure to the syringe. Stop advancing the catheter-over-the-needle when the airway has been entered. This will be signified by a loss of resistance and air bubbles in the syringe (Figure 25-11B).

Hold the syringe securely and advance the catheter over the needle until the hub is at the skin of the neck. Hold the catheter hub securely against the skin of the neck and remove the needle and syringe. Insert and advance the guidewire through the catheter and into the trachea (Figure 25-11C). Grasp the guidewire securely and remove the catheter over the guidewire (Figure 25-11D). Do not release your grasp on the guidewire in order to prevent it from completely entering the patient's airway.

Insert the dilator/airway catheter unit over the guidewire and into the trachea in a semicircular motion (Figure 25-11E). The tip of the dilator is rigid. Insert it gently to prevent injury to or perforation of the posterior tracheal wall. Continue to advance the unit until the flange is against the skin of the neck. Hold the airway catheter securely. Remove the guidewire and dilator as a unit, leaving the airway catheter in place (Figure 25-11F). Begin ventilation of the patient and secure the airway catheter as previously described.

Needle Cricothyroidotomy

A needle cricothyroidotomy, rather than a surgical cricothyroidotomy, should be performed in children less than 8 years of age. The latter is technically more difficult. The child has a laryngeal prominence that is difficult to palpate as it is not well developed. The cricothyroid membrane is small and often will not allow the passage of an airway tube. The larynx is anatomically positioned relatively higher than in an adult and is more difficult to access. A commercially available kit (ENK Oxygen Flow Modulator Set, Cook Inc., Bloomington, IN) or commonly available equipment in the Emergency Department may be used to perform this procedure.

Stand at the side of the bed and adjacent to the patient's head and neck.11 Reidentify the anatomic landmarks. This is crucial to performing this procedure. Using the nondominant hand, place the thumb on one side of the thyroid cartilage and the middle finger on the other side. Use these fingers to stabilize the larynx.8,14 Use the index finger to identify the anatomic landmarks.4,5,11 Start at the laryngeal prominence (Adam's apple) and work inferiorly. The soft membranous defect inferior to the laryngeal prominence is the cricothyroid membrane. Below this is the cartilaginous ring of the cricoid cartilage.

Attach a 12 to 16 gauge catheter-over-the-needle (angiocatheter) onto a 10 mL syringe containing 5 mL of sterile saline. Insert the catheter-over-the-needle through the skin, subcutaneous tissue, and inferior aspect of the cricothyroid membrane. The inferior aspect of the cricothyroid membrane is the preferred site, as use of it avoids injury to the cricothyroid arteries. Direct the catheter-over-the-needle inferiorly and at a 30° to 45° angle (Figure 25-12A). Maintain constant negative pressure within the syringe as it is advanced (Figure 25-12B). Continue to advance the catheter-over-the-needle while maintaining negative pressure until air bubbles are visible in the syringe and a loss of resistance is felt. These both signify that the catheter-over-the-needle is within the trachea.

Once placement within the trachea is confirmed, securely hold the needle and advance the catheter until the hub is against the skin (Figure 25-12C). Remove the needle and syringe (Figure 25-12C). Reattach the syringe without the needle to the catheter. Aspirate once again to reconfirm placement of the catheter within the trachea. The 2 to 3 cm catheter should be long enough to pass into the trachea without sitting against the posterior wall. If the catheter tip directly touches or faces the posterior tracheal wall, there is the risk of forcing air submucosally. Grasp and hold the catheter hub firmly at the skin of the neck. Remove the syringe. Attach the oxygen tubing to the catheter (Figure 25-12D). Begin ventilation and continue until a more permanent and secure airway is established.

At this point, the patient may be oxygenated and ventilated by two methods. The first involves inserting the adapter piece from a #3.0 endotracheal tube to the catheter hub and then connecting it directly to the bag-valve device or a ventilator. This method allows for the confirmation of breath sounds and provides better ventilation of the patient.

The second method of oxygenation involves direct connection of the high-flow oxygen tubing to the hub of the catheter. This method requires cyclic ventilation for 1 to 2 seconds followed by exhalation for 4 to 5 seconds.12 This method provides adequate oxygenation but less adequate ventilation and is more labor-intensive. The complete details of percutaneous transtracheal jet ventilation can be found in Chapter 24.

Once breath sounds are confirmed, the catheter can be secured to the skin. This may be done with nylon sutures or strips of adhesive tape. The patient should undergo orotracheal intubation or a formal tracheostomy as soon as possible because of the risk of dislodging the catheter and the suboptimal ventilation associated with this technique.

If a tracheostomy tube is not available, an endotracheal tube can be used. The endotracheal tube is much longer than is needed. Remove the 15 mm connector from the proximal end of the endotracheal tube. Cut the endotracheal tube with scissors just above where the tubing to inflate the cuff enters the tube. Place the 15 mm connector on the shortened endotracheal tube. The procedure to insert an endotracheal tube is the same as that for a tracheostomy tube.

A cricothyroidotomy is a seldom performed procedure. A tracheal hook may not be immediately available or found when one is required. A simple alternative is to make one using a 16 or 18 gauge needle, a 10 mL syringe, and a hemostat or needle driver (Figure 25-13). Securely apply the needle onto the syringe. Use the hemostat or needle driver to place two 90° bends in the distal needle (Figure 25-13). The syringe acts as a handle and the bent needle as a tracheal hook.

Numerous other percutaneous cricothyroidotomy kits are available. The QuickTrach (Rusch Inc. of Teleflex Medical, Research Triangle Park, NC) is a preassembled, one-piece device (Figure 25-14). The Bivona Nu-Trake (Smiths Medical, Inc., Gary, IN) is also preassembled, but requires the use of an obturator (Figure 25-15). These devices are quick, simple to use, and do not require the use of a guidewire or the Seldinger technique. These are more likely to be used in the prehospital setting than in the Emergency Department.

The use of a bougie or endotracheal tube introducer may aid the performance of a surgical cricothyroidotomy.26 Begin the procedure as described previously. Once the airway is controlled with the tracheal hook, insert a bougie or endotracheal tube introducer through the incision, directed inferiorly, and into the trachea. The bougie or endotracheal tube introducer will provide tactile feedback as it crosses the tracheal rings. Advance the tracheostomy tube or endotracheal tube over the bougie or endotracheal tube introducer and into the trachea. The major advantages of these devices are their lengths. It will not pull out and it will ensure that the tract is not lost.

Several quick assembly and low cost needle cricothyroidotomy setups can be put together quickly with commonly available equipment in the Emergency Department.27 Insert a catheter-over-the-needle as previously described. Remove the needle, leaving the angiocatheter through the skin and into the airway. Attach and connect the following components in the listed order to the hub of the angiocatheter. The first consists of a 3.5 mm endotracheal tube respiratory adapter and a bag-valve device. The second consists of a 10 mL syringe without the plunger, a 7.0 mm endotracheal tube inserted into the syringe, and a bag-valve device. The third consists of a 3 mL syringe without the plunger, a 7.0 mm endotracheal tube respiratory adapter, and a bag-valve device. The fourth consists of the cut distal 10 cm of an intravenous infusion tubing, a 2.5 mm endotracheal tube respiratory adapter, and a bag-valve device.

Immediately after securing the tracheostomy tube, confirm its proper positioning by auscultation of bilateral breath sounds, chest rise, and end-tidal CO2 monitoring. Obtain a chest radiograph to confirm the position of the tube and rule out the presence of a pneumothorax.12

The tracheostomy tube should be held in place firmly while the patient is ventilated with a bag-valve device or a ventilator.11 Do not release the hold on the tracheostomy tube until it is secured. Obtain hemostasis of the wound edges by grasping any bleeding vessels with a hemostat and place an absorbable 3-0 suture over the vessel. If the skin incision is significantly larger than the tracheostomy tube, pack the wound with iodoform gauze. Secure the tracheostomy tube by placing twill tape (tracheostomy tape) through one end of the flange, around the patient's neck, and through the other end of the flange.11,12 An alternative is to suture the four corners of the tracheostomy flange to the patient's skin using 3-0 nylon suture.

If an endotracheal tube was inserted, it should also be secured. Wrap tape around the endotracheal tube as it exits the incision site. Wrap the tape around the patient's neck and back onto the endotracheal tube. Alternatively, a commercially available endotracheal tube holder can be used to secure the tube.

The tracheostomy or endotracheal tube can be removed easily when the indication for airway control no longer exists. This usually occurs after the patient is orotracheally intubated, nasotracheally intubated, or has a formal tracheostomy performed. After removal of the tube, place an occlusive dressing, such as petroleum gauze, over the incision until it heals. If the patient is predicted to require ventilatory management for more than 7 days, it is advised that the cricothyroidotomy be converted to a formal tracheostomy to minimize the risk of long-term complications.

Complications following a cricothyroidotomy can be classified as early or late based on when they occur. Early complications will be recognized either immediately after insertion of the tracheostomy tube or within a few hours. Late complications may not be apparent for weeks to months following the procedure.

The most serious early complication is malposition of the tracheostomy tube within the soft tissues of the neck. If the tube is not within the trachea, the patient cannot be ventilated or oxygenated. This, fortunately, is easily recognized on auscultating the chest. It can be remedied by removing the tracheostomy tube and replacing it in its proper location. The tube may also be misplaced above or below the cricothyroid membrane. Placement above the cricothyroid membrane often results from inadequate palpation of landmarks and is associated with an incision into the larynx. The airway should be converted to a tracheostomy once this malposition is recognized.6 Placement below the cricoid cartilage has been estimated to occur in 10% of cricothyroidotomies.2 There is no specific treatment required for this other than the recognition that the patient actually has a high tracheostomy.

Laryngeal injury may occur if the tracheostomy tube that is inserted is larger than the cricothyroid membrane. The cricothyroid membrane is only 9 to 10 mm in height in the average adult.8,11 Placement of a tracheostomy tube with a larger outer diameter may cause a fracture of the thyroid cartilage. It is important that the tracheostomy tube placed is no larger than a #6.0 or a #7.0.8,11 Placement of a larger tube is also associated with an increased incidence of subglottic granulation and stenosis.2,4

Incisional bleeding occurs in 4% to 8% of patients following a cricothyroidotomy.2,4,6,8,15 This may result from transection of the anterior jugular veins if the incision extends too far laterally. Bleeding is usually easily treated by point ligation of the bleeding vessels and packing around the tracheostomy tube with iodoform gauze. A small amount of bleeding or oozing from the cricothyroid arteries can be tamponaded by packing iodoform gauze around the tracheostomy tube.

An emergent cricothyroidotomy is usually performed in less than sterile circumstances. There is thus a risk of developing a wound infection.15 This is usually the result of skin flora. It can often be treated with wet-to-dry saline dressing changes. Occasionally, the infection will not resolve until the cricothyroidotomy tube has been removed, either by decannulation or conversion to a formal tracheostomy. Antibiotics are usually not required.

Late complications take two general forms: progressive airway obstruction and chronic voice changes. Patients with progressive airway obstruction present with slowly increasing stridor and dyspnea weeks to months after the procedure. This usually results from subglottic stenosis and granulation tissue formation at the site of the stoma.2,6,13 It is unclear whether this complication results from the cricothyroidotomy or the tracheostomy tube. The majority of these patients have had prolonged endotracheal intubations before the cricothyroidotomy or prolonged tracheostomy placement after the cricothyroidotomy.2,13,14,16 In one series, patients with a cricothyroidotomy for a prolonged period (average 72 days) had a 52% incidence of chronic obstruction compared to no obstruction in patients with cricothyroidotomy for a shorter period (average 27 days).16 Another study recommended that the tracheostomy tube be removed by the fourth day to minimize these long-term complications.9

A final late complication is that of voice changes. This has been described in up to 25% of patients that received a cricothyroidotomy.6,13–15 Again, many of these patients had other methods of airway management either before or after the cricothyroidotomy. Voice changes tend to be somewhat nonspecific. Patients will complain of hoarseness, decreased volume, and fatigue. These changes may be due to small amounts of granulation tissue at the stoma site and generally resolve over time.4

A cricothyroidotomy is a potentially lifesaving airway management technique. It is an important procedure for the Emergency Physician to be skilled in, as it may represent the only access to the patient's airway. It can be used to provide oxygenation and ventilation to a patient when other less invasive airway control methods have failed or are contraindicated. It is a relatively safe, simple, and reliable procedure that can be performed within a few minutes. A self-contained percutaneous cricothyroidotomy kit is commercially available and simple to use. Knowledge of the anatomy of the anterior neck is essential in order to minimize complications.