Abstract
When attempts at orotracheal intubation or airway rescue techniques (e.g., laryngeal mask airway) have failed in a patient who cannot oxygenate or ventilate, cricothyroidotomy is the emergency surgical airway of choice. It can be performed open or percutaneously. The approach should be dictated by the proceduralist’s preference and experience.
General Principles
When attempts at orotracheal intubation or airway rescue techniques (e.g., laryngeal mask airway) have failed in a patient who cannot oxygenate or ventilate, cricothyroidotomy is the emergency surgical airway of choice. It can be performed open or percutaneously. The approach should be dictated by the proceduralist’s preference and experience.
In pediatric patients (<12 years), cricothyroidotomy is relatively contraindicated because the risk of long-term complications, such as stenosis, are especially high. Transtracheal needle jet ventilation should be considered in these patients, as a temporary oxygenation and ventilation alternative, while preparing for a more definitive airway management.
The cricothyroid membrane is identified externally as the soft space immediately below the thyroid cartilage (Figure 18.1).
In patients with obscured anatomy (e.g., body habitus, neck trauma), the four-finger technique is a useful method of rapidly estimating the surface landmark for the cricothyroid membrane (Figure 18.2)
With the proceduralist’s four fingers extended next to one another, the small finger is placed onto the patient’s sternal notch. The tip of the index finger approximates the location of the cricothyroid membrane in this position.
It is not necessary to convert a cricothyroidotomy to a tracheostomy after patient stabilization.
Figure 18.1 Surface anatomy for cricothyroidotomy.
Special Surgical Instruments
At a minimum, a scalpel and an endotracheal or tracheostomy tube are required to perform an open cricothyroidotomy. Optimally, a tracheal hook, bougie, Senn retractors, Kelly clamp, Metzenbaum scissors, and forceps should also be available (Figure 18.3)).
There are several commercially available percutaneous cricothyroidotomy sets (Figure 18.4).
If percutaneous cricothyroidotomy is performed, the equipment for open cricothyroidotomy should be present bedside in case conversion is required.
Suction, lighting, bag valve mask, an end-tidal CO2 detector, and endotracheal/tracheostomy tubes of various sizes should be immediately available.
Positioning
If cervical spine precautions must be maintained, cricothyroidotomy can be performed with the neck in neutral position. If the cervical spine has been cleared, neck extension and placement of a shoulder roll will help bring the airway into an anterior position, thereby facilitating cricothyroidotomy (Figure 18.5).
Figure 18.5 Patient positioning for cricothyroidotomy. If the cervical spine has been cleared, neck extension and placement of a shoulder roll will help bring the airway into an anterior position, thereby facilitating cricothyroidotomy. If cervical spine precautions must be maintained, cricothyroidotomy can be performed with the neck in neutral position.
Open Cricothyroidotomy
Surgical Anatomy
The cricothyroid membrane is located in the midline anteriorly, between the thyroid cartilage above and the cricoid cartilage below (Figure 18.6A).
Laterally, it is partially covered by the paired cricothyroid muscles (Figure 18.6B).
The uncovered, medial portion of the cricothyroid membrane is the target for cricothyroidotomy.
