Cricothyrotomy

• Failure of oral or nasal intubation or adequate oxygenation and ventilation with airway adjuncts (laryngeal mask airway, etc.).
• Massive oral, nasal, or pharyngeal hemorrhage
• Masseter muscle spasm
• Clenched teeth
• Structural deformities of the oropharynx, whether congenital or acquired
• Stenosis of the upper airway (pharynx or larynx)
• Laryngospasm
• Mass effect (cancer, tumor, polyp, web, or other mass)
• Airway obstruction (partial or complete)
• Oropharyngeal edema
• Foreign body obstruction
• Obstruction of the airway due to displacement of normal structures

• Age under 5 to 12 years
• Tracheal transection or low obstruction
• Relative contraindications: difficulty identifying anatomic structures due to swelling, trauma, previous radiation therapy, injury, etc.

• Scalpel with No. 11 blade
• Mayo scissors
• Tracheal hook
• Tracheal dilator (Trousseau dilator) or spreader
• Hemostat
• Cuffed size 4 tracheostomy tube (nonfenestrated) with trocar
• Cuffed size 6.0 endotracheal tube
• 25-gauge needle and syringe containing lidocaine with epinephrine
• Betadine (or other skin prep solution)
• Sterile gauze pads
• Sterile tracheal suction catheter
• Cotton twill to secure the tube
• Melker technique kit
  • The Melker Emergency Cricothyrotomy Catheter Kit (Cook Critical Care, Bloomington, Ind)

• Cricothyroid membrane
  • It is bordered superiorly by the thyroid cartilage and inferiorly by the cricoid cartilage.
  • The membrane is identified as a shallow depression just below the thyroid cartilage and measures about 1 cm longitudinally and 2 to 3 cm transversely.
  • If swelling is present, the cricothyroid membrane may be estimated to be about 2 to 3 cm inferior to the laryngeal prominence or 4 fingerbreadths above the sternal notch.

• Cricoid cartilage
• The tracheal rings descend inferiorly from the cricoid cartilage.

Figure 1 :  Cricothyrotomy

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Figure 4 :  Equipment for surgical cricothyrotomy

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Figure 6 :  Cricothyroid membrane

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The full content of this section includes:

• Step-by-step text instructions for performing the procedure
  
• Clinical pearls providing practical clinical tips from medical experts
• Patient safety guidelines consistent with Joint Commission and OHSA standards
• Links to medical evidence and related procedures

Figure 9 :  Make a vertical incision through the skin

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Figure 10 :  Make a horizontal incision through the cricothyroid membrane

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Figure 13 :  Insert the airway while rotating the dilator

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Figure 14 :  Insert the over-the-needle catheter through the cricothyroid membrane

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Figure 15 :  Advance the catheter into the trachea and thread the guidewire through it

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• Confirm proper placement of the tracheostomy tube.
• After confirming proper placement, suture the tracheostomy tube into place.
• Obtain a post-procedure chest radiograph.

• Given that surgical cricothyrotomy is infrequently performed, inherently chaotic, and performed on a patient population with confounding medical issues and a high morbidity and mortality rate, the evaluation of short-term and long-term complications is difficult.
• Bleeding
• Misplacement of the tracheostomy or ET tube
• Occult complications
• Mainstem bronchial intubation
• Laryngotracheal injury
• Tension pneumothorax
• Clogging of the tracheostomy tube with blood or secretions
• Slobodkin et al report one case of retrograde pharyngeal intubation.