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.
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
The cricothyroidotomy site. The dotted line represents the incision over the cricothyroid membrane.
A surgical cricothyroidotomy. A. The nondominant hand stabilizes the cricothyroid membrane. A transverse incision is made through the skin, subcutaneous tissue, and cricothyroid membrane. B. A tracheal hook has been inserted over the scalpel blade to grasp the inferior border of the thyroid cartilage. The hook is lifted anteriorly and superiorly to control the airway (arrow). C. A Trousseau dilator is inserted into the incision and opened to dilate the incision site. D. A tracheostomy tube is inserted through the cricothyroid membrane.
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
An alternative method to perform a surgical cricothyroidotomy. A. The thyroid cartilage is secured while a stab incision is made in the cricothyroid membrane. B. The scalpel blade penetrates the midline and enters the airway. C. The incision is extended laterally from the midline. D. The scalpel is rotated 180° and extends the incision to the other side. E. A tracheal hook is inserted in the midline and grasps the inferior border of the thyroid cartilage. F. The thyroid cartilage is lifted anteriorly and superiorly to control the airway (arrow). After the airway is controlled, the scalpel is removed. G. A Trousseau dilator is inserted into the incision, and the jaws are opened to dilate the incision. H. A tracheostomy tube is inserted into the trachea using a semicircular motion.
The alternative method performed on a cadaver. A. The larynx is stabilized and the Emergency Physician's index finger overlies the cricothyroid membrane. B. A stab incision is made into the cricothyroid membrane using the finger as a guide. C. The incision is extended toward the Emergency Physician. D. The scalpel is rotated 180° and the incision is extended away from the Emergency Physician. E. A tracheal hook is inserted over the scalpel blade to grasp the inferior border of the thyroid cartilage. F. The tracheal hook is lifted upward and superiorly to control the airway. The scalpel has then been removed. G. The Trousseau dilator is inserted into the cricothyroid membrane. H. The jaws of the dilator are opened in the sagittal plane to widen the incision. I. The dilator is rotated 90°. J. The jaws of the dilator are opened to open the incision transversely. K. An endotracheal tube is inserted through the incision and into the trachea.
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.
Cricothyroidotomy in a patient with neck swelling. A. Locate the hyoid bone. Line 1 is from the angle of the mandible to the tip of the chin. Line 2 is half the length of line 1 and perpendicular to it. Line 3 is from the end of line 2 to the angle of the patient's mandible. B. A #11 scalpel blade is inserted in the midline and aimed along line 3 until it contacts the hyoid bone. C. An alternative method. A spinal needle is used to locate the hyoid bone. A #11 scalpel blade is inserted along the tract of the spinal needle until the hyoid bone is contacted. D. A tracheal hook is inserted along the scalpel blade and used to grasp the hyoid bone. The tracheal hook is lifted (arrow) anteriorly and superiorly to elevate and control the airway.
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.
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 (Cook Critical Care, Bloomington, IN).
The dilator is placed inside the airway catheter to form a unit. The pediatric unit (left) and the adult unit (right) are both contained within each percutaneous cricothyroidotomy kit.
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).
The percutaneous cricothyroidotomy. A. A stab incision is made in the midline over the cricothyroid membrane. B. A catheter-over-the-needle is inserted at a 30° to 45° angle to the skin and advanced in a caudal direction. Negative pressure is applied to a saline-containing syringe during catheter insertion. Air bubbles in the saline confirm intratracheal placement of the catheter. C. The catheter has been advanced until the hub is against the skin. The needle and syringe have been removed. A guidewire is inserted through the catheter. D. The catheter has been removed, leaving the guidewire in place. E. The dilator/airway catheter unit are advanced over the guidewire. F. The guidewire and dilator have been removed, leaving the airway catheter in place.
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.
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.
Needle cricothyroidotomy. A. The catheter-over-the-needle is inserted 30° to 45° to the perpendicular (dotted line) and aimed inferiorly. B. Application of negative pressure (arrow) to a saline-containing syringe during catheter-over-the-needle insertion. Air bubbles in the saline confirm intratracheal placement of the catheter. C. The catheter is advanced until the hub is against the skin. The needle and syringe are then removed. D. High-pressure oxygen tubing is attached to the catheter and ventilation is begun.
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.