Cricothyrotomy (General Surgery)

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  • 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.

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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

  • 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.
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