Cricothyrotomy

A cricothyrotomy (also called thyrocricotomy, cricothyroidotomy, inferior laryngotomy, intercricothyrotomy, coniotomy or emergency airway puncture) is an emergency incision through the skin and cricothyroid membrane to secure a patient's airway during certain emergency situations, such as an airway obstructed by a foreign object or swelling, a patient who is not able to breathe adequately on their own, or in cases of major facial trauma which prevent the insertion of an endotracheal tube through the mouth. A cricothyrotomy is usually performed by emergency physicians, trauma surgeons, or paramedics as a last resort when control of the airway by usual means (an endotracheal tube through the mouth) have failed or are not feasible. This technique is considered easier and faster than a tracheostomy, but is only used when oral or nasal intubation is not possible. This procedure does not require manipulation of the cervical spine. However, for a non-physician, it does require special training and authorization from local medical direction prior to being performed, depending on local medical protocols.

Cricothyrotomy is only a temporary airway for life-saving situations. It is not suitable for prolonged ventilation due to its small size. A definitive airway (tracheostomy or endotracheal intubation) must be performed later in hospital.

Indications

Severe facial or nasal injuries (that do not allow oral or nasal intubation)
Massive midfacial trauma
Possible cervical spine trauma preventing adequate ventilation
Anaphylaxis
Chemical inhalation injuries

Contraindications

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)

Procedure

The procedure was first described in 1805 by Vicq d'Azyr, a French surgeon and anatomist. A cricothyrotomy is generally performed by making an incision on the skin of the neck just below the "Adam's apple", or thyroid cartilage, then making another 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.

Summarized technique

With a scalpel, create a 1 cm transverse incision through the cricothyroid membrane
Open the hole by inserting the scalpel handle into the wound and rotating 90 degrees or by using a clamp
Insert a 6 or 7 mm Internal Diameter tracheostomy tube or endotracheal tube
Inflate the cuff and secure the tube
Provide venilation via a bag-valve device with the highest available concentration of oxygen
Determine if ventilation was successful (bilateral ausculation and observing chest rise and fall)
No attempt should be made to remove the endotracheal tube in a prehospital setting.

Cricothyrotomy in popular media

On the TV show M*A*S*H, 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 the 1980 Nicolas Roeg film "Bad Timing," Theresa Russell's character Milena Flaherty has an emergency cricothyrotomy performed following an intentional overdose.

In Grey's Anatomy, emergency cricothyrotomy is mentioned in at least two 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 throacotomy.
In “The Heart of the Matter,” Izzie performs her first “emergency crike” on Camille, a niece of Chief of Surgery Dr. Richard Webber.

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.

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 anaphylaxis. Lake calls for emergency assistance, but impatient and 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.

References

Barone, Jeanine. Tracheotomy. health.enotes.com. URL last accessed February 28 2006.
Brookside Associates; US Army Medical department. Cricothyroidotomy. www.brooksidepress.org. URL last accessed February 28 2006.
Dorland's Illustrated Medical Dictionary. URL last accessed February 28 2006.
Reis, Carlos. Cricothyroidotomy. www.medstudents.com.br. URL last accessed February 28 2006.
SIAARTI study committee on the difficult airway. SIAARTI guidelines for difficult intubation and for difficult airway management. anestit.unipa.it. URL last accessed February 28 2006.
Mosby's Paramedic Textbook, Edition 3, Mick J. Sanders. 2005, St. Louis, MI: Elsevier Mosby.

External links

Open Emergency Cricothyrotomy
Drawing of a cricothyrotomy
Smiths Medical (Cricothyroidotomy products for Adults and Children)
Medstudents: Procedures: Cricothyrotomy