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, surgeons, field medics, or paramedics. Usually it is performed 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

Can't intubate
Can't ventilate
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 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.

Summarized technique

With a scalpel, create a 1 cm vertical incision through the skin and 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 ventilation 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 tracheostomy or endotracheal tube in a prehospital setting

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

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