A cricothyrotomy (also called thyrocricotomy, cricothyroidotomy, inferior laryngotomy, intercricothyrotomy, coniotomy or emergency airway puncture) is an incision made through the skin and cricothyroid membrane to establish a patent airway during certain life-threatening situations, such as airway obstruction by a foreign body, angioedema, or massive facial trauma. Cricothyrotomy is nearly always performed as a last resort in cases where orotracheal and nasotracheal intubation are impossible or contraindicated. Cricothyrotomy is easier and quicker to perform than tracheotomy, does not require manipulation of the cervical spine, and is associated with fewer complications. However, while cricothyrotomy may be life-saving in extreme circumstances, this technique is only intended to be a temporizing measure until a definitive airway can be established.
- Can't intubate
- Can't ventilate
- Severe facial or nasal injuries (that do not allow oral or nasal tracheal intubation)
- Massive midfacial trauma
- Possible cervical spine trauma preventing adequate ventilation
- Chemical inhalation injuries
- Inability to identify landmarks (cricothyroid membrane)
- Underlying anatomical abnormality (tumor)
- Tracheal transection
- Acute laryngeal disease due to infection or trauma
- Small children under 10 years old (a 12–14 gauge catheter over the needle may be safer)
The procedure was first described in 1805 by Vicq d'Azyr, a French surgeon and anatomist. A cricothyrotomy is generally performed by making a vertical incision on the skin of the neck just below the "Adam's apple", or thyroid cartilage, then making another transverse incision in the cricothyroid membrane which lies deep to this point. One then inserts a tube into this opening, which allows one to breathe for the patient with a machine or bag.
A needle cricothyotomy is similar, but instead of making a scalpel incision, a large over-the-needle catheter is inserted (12- to 14-gauge). This is considerably simpler, particularly if using specially-designed kits. This technique provides very limited airflow. The delivery of oxygen to the lungs through an over-the-needle catheter inserted through the skin into the trachea using a high pressure gas source is considered a form of conventional ventilation called percutaneous transtracheal ventilation (PTV).
There is some evidence that (as commonly depicted in popular culture) a ballpoint pen barrel can be, in lieu of a needle, used successfully in extremis to restore an airway.
- Surgical procedure
In a typical cricothyrotomy procedure, a scalpel is used to create a 1 cm vertical incision through the skin and the cricothyroid membrane. In an emergent situation or for patients with significant obesity a larger vertical incision may be required. The resulting hole is opened by either inserting the scalpel handle into the wound and rotating 90 degrees or by using a clamp. A tracheostomy tube or endotracheal tube with a 6 or 7 mm internal diameter is then inserted, the cuff is inflated, and the tube is secured. A bag-valve device with the highest available concentration of oxygen is used to provide ventilation, the success of which is assessed by bilateral ausculation and observation of the rise and fall of the chest. No attempts are made to remove the tracheostomy or endotracheal tube in a prehospital setting.
Cricothyrotomy in popular media
On the TV show M*A*S*H[specify], Father Mulcahy performs an emergency cricothyrotomy on a patient. With the direction of Dr. Pierce via radio, he uses a pen knife and an eye dropper to perform the operation. Needless to say, this would be extremely dangerous in real life. Even under ideal, clinical conditions, a cricothyrotomy is difficult and requires specific tools, preparation and a practiced knowledge of anatomy. There are many major blood vessels and nerves in the neck and cutting there, even with the best of intentions carries a high risk of harming the patient.
In Grey's Anatomy, emergency cricothyrotomy is mentioned in at least three episodes:
- In “Owner of a Lonely Heart,” Cristina almost performs an emergency cricothyrotomy on a patient who swallowed a light bulb. Before she is able to do so, however, Dr. Burke shows up and takes the patient to an operating room where he proceeds to perform an emergency thoracotomy.
- In “The Heart of the Matter,” Izzie performs her first “emergency crike” on Camille, a niece of Chief of Surgery Dr. Richard Webber.
- In "I Saw What I Saw" Alex performs a "crike" on the patient who later dies.
In the ER episode "Reason to Believe" Dr. Kerry Weaver performs an emergency cricothyrotomy on a student. She is shooting a news segment on childhood obesity in an elementary school cafeteria when one of the students begins to choke; after the heimlich maneuver fails, she performs a cricothyrotomy with a kitchen knife and a drinking straw. It is also used many other times, especially in the trauma room, when an airway can't be established.
In the movie Playing God (1997), David Duchovny plays a famed LA surgeon, stripped of his license due to drug abuse, who finds himself witnessing a gun fight at a bar. He saves a mafia crime figure by performing an emergency cricothyrotomy. This endears him with the mafia family and drives the plot forward.
In the BBC3 medical drama Bodies, the main protagonist Rob Lake, a newly appointed obstetrics and gynaecology registrar (played by Max Beesley), is called to a patient who is having difficulty breathing due to epiglottitis. Lake calls for emergency assistance but help is slow coming, so fearing for the patient's life decides to undertake a cricothyrotomy himself - a procedure he has not been trained in. The procedure is unsuccessful and the patient dies before help arrives. The guilt surrounding the event combined with the covering up by his consultant provides an important backdrop to the further development of the character and his relationship with his consultant.
On Dr. Quinn, Medicine Woman; Sully, the white man raised by Indians who is her lover and companion, performs the procedure on one of Dr. Quinn's boys using a bird's feather (the base where it is hollow).
On the New Zealand Soap opera Shortland Street, Series 21, Episode 5104 / 5105, Student doctor Paige Munroe Performs a Cricothyrotomy with a pocket knife and pen and saves a woman's life, even though she was not qualified (and nervous).
- M. Gregory Katos and David Goldenberg (June 2007). "Emergency cricothyrotomy". Operative Techniques in Otolaryngology 18 (2): 110–114. doi:10.1016/j.otot.2007.05.002. Retrieved 25 July 2010.
- Neill, A.; Anderson, P. (2012). "Observational cadaveric study of emergency bystander cricothyroidotomy with a ballpoint pen by untrained junior doctors and medical students". Emergency Medicine Journal. doi:10.1136/emermed-2012-201317. PMID 22562071.
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