During life-threatening situations, the airway of a patient may be severely compromised. The condition requires critical and timely intervention by establishing a front-of-neck access (FONA) emergency airway, otherwise known as emergency cricothyrotomy or cricothyroidotomy.
Cricothyroidotomy is performed as a final resort when conventional airway management techniques are unsuccessful or cannot be administered due to a difficult airway situation.
Let’s explore all there is to this emergency procedure, including its pediatric use and the risks associated with it.
What Is an Emergency Cricothyrotomy?
In challenging “can’t intubate, can’t oxygenate, can’t ventilate” situations where facemasks, tracheal tubes, and supraglottic airway devices are ineffective in airway management, the situation may call for an emergency cricothyroidotomy.
The urgent, specialized procedure creates an airway by creating front-of-neck access. It is typically employed when the patient is choking or unable to breathe. It is also often necessary in situations such as profuse oral hemorrhage, copious emesis, oral or maxillofacial trauma, cervical spine trauma, or due to anatomic abnormalities that hinder endotracheal intubation.
Ancient Egyptian hieroglyphics indicate that the procedure has been used to bypass obstructed airways for thousands of years. Considered more straightforward than a tracheostomy, it is the method of choice when other non-invasive procedures fail.
Though surgeons undergo proper training before conducting an emergency cricothyroidotomy, most emergency physicians or hospitalists only have a superficial knowledge of the procedure.
It entails the placement of a tube or needle into the neck using a variety of techniques that include:
This procedure is more technical in nature and requires an incision over the cricothyroid membrane to enable tissue dissection. Then, a tracheal hook is inserted to retract the cricoid or thyroid cartilage before a large bore cricothyroidotomy cannula is placed. It is then secured to facilitate conventional ventilation.
This is used as a temporary measure during extreme emergencies when open cricothyrotomy isn’t viable.
The technique requires a 3-centimeter vertical incision on the cricothyroid membrane to allow the insertion of a needle and wire. Once they are in place, a cannula that has a pre-loaded dilator will be used at the opening.
Note that Seldinger cricothyroidotomy comes with certain risks such as:
- Subglottic stenosis
- Oesophageal puncture
- Obstruction of the upper airway
- Subcutaneous emphysema
- Respiratory acidosis due to hypoventilation
- Mediastinal emphysema
- Vocal cord injury
However, with proper administration by a trained healthcare provider, these risks can be reduced while effectively facilitating conventional ventilation.
Trans-Tracheal Catheter Cricothyroidotomy
This technique relies on the placement of a trans-tracheal catheter through gentle aspiration with the goal of cannulating the trachea. A trans-tracheal catheter is carefully inserted to provide oxygen through an oxygen flow modulator, self-inflating bag, or jet ventilator.
There are several variations of this technique. They differ based on the use of the scalpel and if a tracheal hook is employed.
This procedure takes less time than the cannula-to-Melker procedure and involves the horizontal dissection of the tissue above the cricothyroid membrane.
A tracheal hook is inserted and retracted before a bougie is placed into the trachea and an endotracheal tube (ET) is inserted over the bougie and positioned to enable conventional ventilation.
Emergency Cricothyroidotomy in Adults and Children
Emergency cricothyrotomy is often performed to create an emergency airway when a patient is choking.
It entails making a small cut in the skin and membrane in the throat which will allow the insertion of a hollow needle or tube between the thyroid cartilage and cricoid cartilage.
The majority of emergency cricothyroidotomy kits are designed for adults. The devices are thus only appropriate for teenagers and adults, not for infants and neonates. This is because infants have a unique anatomy of the larynx and a smaller cricothyroid membrane.
It is thus difficult to locate the accurate anatomical structures of infants using the same tools. Cricothyrotomy kits should not be used on them because the procedure would be too impractical and dangerous.
Emergency cricothyroidotomy for infants requires special airway devices such as the Quicktrach baby which is specifically designed for infants. The set includes a plastic cannula over a metal needle to enable direct placement in the trachea. It has proven to be a reliable tool for establishing quick and effective emergency airways among infants.
Benefits and Risks of Emergency Cricothyroidotomy
Emergency cricothyrotomy is associated with certain risks such as:
- Esophageal injuries
- Damage to the larynx or voice box
- Obstruction of the tube due to vomiting
- Cuff injuries
- Tube kink
- Infection and bleeding from the incision
- Injured thyroid gland
- Cephalad displacement of the intubation tube
To avoid these risks, trained healthcare professionals should conduct the procedure with care and precision. Additionally, since an emergency cricothyrotomy is the last resort in “can’t intubate, can’t oxygenate” (CICO) situations, its benefits outweigh the risks. Despite its complications, it is an important and necessary procedure for life-and-death situations.
How To Enhance Outcomes
Safe and effective emergency cricothyroidotomy can be performed if healthcare professionals receive proper practice and training.
The outcomes of this airway management technique can be improved by:
- Receiving anatomical education so that clinicians can efficiently pinpoint the cricothyroid membrane by palpation among anesthetized patients
- Encouraging familiarity with the equipment and contents of the emergency cricothyrotomy kit to improve efficiency
- Regular practice through simulation training
While surgeons have the required training to perform cricothyrotomies effectively, it is essential that all medical personnel have the ability to conduct the procedure during emergencies.
Effective airway management is crucial during life-or-death situations. Though there are risks involved, emergency cricothyrotomy is an effective and critical procedure. It ensures optimal oxygenation by securing an airway and avoiding severe hypoxia. Proper training is a must since it’s considered an advanced technique.
To learn more about emergency cricothyrotomy, Hospital Procedures Consultants’ Airway Management Course can help you master your airway management skills with simulation-based procedural training.
See Seong Chang. Qian Jun Tong. Zhi Yuen Beh. Howyow Quek, K. Bun Hui Ang. A bench study comparing between scalpel-bougie technique and cannula-to-Melker technique in emergency cricothyroidotomy in a porcine model. Korean J Anesthesiol. 2018. 71. 289–295.
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