Cricothyroidotomy—Standard and Needle

imagesTo provide emergent airway access only when a safer, less invasive airway cannot be established or is contraindicated


imagesFor children younger than 12 years, needle cricothyroidotomy is the surgical airway of choice


CONTRAINDICATIONS



imagesAbsolute


   imagesAn oral or nasal airway can be established


   imagesSignificant injury or fracture of the cricoid cartilage or larynx (tracheostomy is the procedure of choice)


   imagesTracheal fracture or transection


   imagesObstruction below the cricothyroid membrane


   imagesPatients younger than 12 years (needle cricothyroidotomy is the procedure of choice for this age-group)


imagesRelative


   imagesNeck mass, swelling, or cellulitis


   imagesNeck hematoma


   imagesCoagulopathy


LANDMARKS



imagesThe cricothyroid membrane—an elastic membrane located anteriorly and midline in the neck, measuring 9 mm longitudinally and 30 mm transversely. Bordered superiorly by the thyroid cartilage (“Adam’s apple”) and inferiorly by the cricoid cartilage.


imagesIn children, the larynx is positioned more superiorly than in adults and is relatively smaller in size (FIGURES 6.1 and 6.2)


STANDARD CRICOTHYROIDOTOMY



imagesSupplies


   imagesAntiseptic solution, drapes, towel clips


   imagesLidocaine with epinephrine


   imagesNo. 11 blade scalpel with handle


   imagesTracheal hook


   imagesTrousseau dilator


   imagesTracheostomy tube


   imagesNeck tie or sutures


imagesTechnique


   imagesPreparation


      imagesHyperextend the neck to more readily identify landmarks, unless the patient has a known or suspected cervical spine injury


      imagesPreoxygenate the patient by bag-mask ventilation


      imagesTest the integrity of the balloon on the tracheostomy tube by injecting with 10 mL of air


      imagesIf time permits, apply appropriate antiseptic solution and drape the area with sterile towels


      imagesIf time permits and patient is conscious or responding to pain, infiltrate the skin of anterior neck with 1% lidocaine solution with epinephrine



images


FIGURE 6.1 Anatomy of the larynx. The cricothyroid membrane (arrow) is bordered above by the thyroid cartilage and below by the cricoid cartilage. (From Walls RM, Murphy MF. Manual of Emergency Airway Management. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012:162, with permission.)



images


FIGURE 6.2 A: Surface anatomy of the airway. B: The thumb and middle finger immobilize the superior cornua of the larynx; the index finger palpates the cricothyroid membrane. (From Walls RM, Murphy MF. Manual of Emergency Airway Management. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012:163, with permission.)



imagesGeneral Basic Steps


   imagesIdentify the landmarks


   imagesStabilize the larynx


   imagesIncise the skin


   imagesReidentify the cricothyroid membrane


   imagesIncise the cricothyroid membrane


   imagesInsert the tracheal hook


   imagesInsert the trousseau dilator


   imagesInsert the tracheostomy tube


   imagesInflate the cuff and confirm tube position


   imagesSecure the tracheostomy tube


imagesIdentify the Landmarks (See Earlier “Landmarks” Section)


imagesStabilize the Larynx


   imagesGrasp both sides of the thyroid cartilage with the thumb and middle finger using the nondominant hand


   imagesPalpate the depression over the cricothyroid membrane with the index finger


   imagesControl the larynx throughout the procedure by stabilizing it in this manner and reidentify the cricothyroid membrane at any time during the procedure


imagesIncise the Skin


   imagesUsing a no. 11 scalpel blade in the dominant hand, make a vertical midline incision through the skin and subcutaneous tissue approximately 2 to 3 cm in length


   imagesCare should be taken to extend the incision down to but not through any of the deep structures of the neck


imagesReidentify the Cricothyroid Membrane


   imagesUsing the index finger of the nondominant hand, reidentify the cricothyroid membrane while maintaining immobilization of the larynx with the thumb and middle finger


   imagesIf the cricothyroid membrane cannot be palpated, extend the initial incision superiorly and inferiorly and try to palpate again


imagesIncise the Cricothyroid Membrane


   imagesUsing the stabilizing index finger as a guide, incise the cricothyroid membrane at least 1 cm in length in the horizontal direction


   imagesNote that the skin incision is vertical and the incision through the membrane is horizontal


   imagesPlace the index finger into the stoma temporarily while exchanging the scalpel for the tracheal hook



images


FIGURE 6.3 A: The tracheal hook is oriented transversely during insertion. B and C: After insertion, cephalad traction is applied to the inferior margin of the thyroid cartilage. (From Walls RM, Murphy MF. Manual of Emergency Airway Management. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012:166, with permission.)

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Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Cricothyroidotomy—Standard and Needle
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