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Approximately 3% of intubation attempts are in difficult airways where a surgical airway should be anticipated.1 The rate of failed ED intubations and subsequent surgical airway placement is below 0.6%.1 However, it would be prudent to prepare for a “worst case scenario” during all intubations.

The term cricothyroidotomy technically means “vertically incising (splitting) the cricoid and thyroid cartilages,” and coniotomy means “incising the cricothyroid (conic) ligament,” which runs from the cricoid to the thyroid cartilage. Although coniotomy is the correct term for incising between these two cartilages, the term cricothyroidotomy is now commonly used to denote the incision of the cricothyroid ligament.

The indications for an emergency surgical airway are several; however, most emergency surgical airways are performed due to an inability to establish an endotracheal airway in a patient that cannot be oxygenated and ventilated adequately while alternative “rescue” methods are attempted. Difficulty in establishing an airway may be due to anatomy (short, obese neck), a disease state (epiglottitis, laryngeal edema, paralyzed vocal cords, or retropharyngeal abscess), trauma from distortion of the neck by hematoma (cervical fracture or major vessel injury), aspiration of blood (facial trauma), or loss of supporting structures (mandibular fractures). Clinical manifestations of acute airway obstruction are stridor (in a patient who is still able to breathe) or cyanosis. Clinical signs and symptoms are listed in Table 31-1.

Table 31-1 Clinical Manifestations Associated with Acute Airway Obstruction


Needle cricothyroidotomy is the preferred emergency surgical airway in children younger than approximately 10 to 12 years old who cannot be intubated orotracheally or nasotracheally. A 12- or 14-gauge catheter over a needle will support oxygenation in a child until a tracheostomy can be performed in the operating room by a surgeon familiar with the anatomy of a child’s neck. The larynx is easily damaged by surgical cricothyroidotomy, and children have more late airway complications.2

Associated Injuries

Some specific types of trauma usually have a greater potential need for a surgical airway. Penetrating trauma to the neck (gunshot or stab wound) that injures a major artery (carotid, vertebral, or thyroid) and demonstrates an expanding hematoma around the injured artery may cause obstruction of the airway by pressure. If free blood from vascular and pharyngeal or tracheal injuries spills into the oro- or hypopharynx, aspiration of blood is minimized by surgical cricothyroidotomy and placement of a cuffed tube (not needle cricothyroidotomy). Difficulty in establishing an airway occurs in approximately 10% of patients with penetrating cervical trauma.3

Blunt trauma to the neck or face may cause hemorrhage of the soft ...

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