How to perform a cricothyrotomy
Source
Surgeon:
Ville Vänni (trauma surgeon)
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Summary
Focus: Emergency cricothyrotomy with incision through the skin and cricothyroid membrane into the trachea.
Key elements: Bougie and tube insertion, tube fixation and evaluation, aftercare, pitfalls, and complications.
Step-by-Step Technique
Patient Positioning, Anesthesia and Preparation
Place the patient in supine position with the neck in slight extension, unless cervical spine injury is suspected. Place a prop (e.g. a saline bag) under the shoulders, if necessary.
If the patient is in extremis, no local anesthesia is required. Clean the area well with scrub (e.g. Betadine). If the condition of the patient allows it, inject local anesthetic (e.g. lidocaine) with a 5-10 ml syringe first into the skin, then subcutaneously and into the cricothyroid membrane (5-10ml required). Intermittent aspiration while injecting facilitates assessment of depth; aspiration of air bubbles confirms entry into the trachea.
Skin Incision
Inspect and palpate the landmarks: the jugular notch, the cricoid and thyroid cartilages, and the cricothyroid membrane.
Fixate the skin in the operation area with your non-dominant hand and apply moderate pressure in order to hold the trachea in place. Applying pressure should also reduce bleeding.
Make a short, vertical incision in the midline, through the skin and the cricothyroid membrane, straight into the trachea, with a No. 11 blade. Rock the scalpel or turn it 180 degrees in the wound, in order to widen the incision sufficiently for tube insertion.
Be aware of the surrounding structures and avoid damaging them: the vocal cords cranially, the thyroid isthmus caudally, the esophagus dorsally, and the sternohyoid muscles and anterior neck veins laterally.
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Insert Bougie and Tube
Remove the scalpel and insert a bougie through the incision into the trachea. Direct it caudally and advance it as long as it slides in effortlessly. If advancing the bougie requires any force, you are in the wrong space. You should be able to “feel” the tracheal rings with the tip of the bougie as you guide the bougie deeper.
Hold the bougie with your non-dominant hand and slide the tube into the trachea with your dominant hand. Remember that the trachea is only about 7cm long, avoid inserting the tube too deep. The depth is right when the cuff is inside of the trachea. Placing the tube too deep could result in bronchial intubation.
Inflate the cuff and remove the bougie.
Attach the tube to the ventilator.
Tube Fixation and Evaluation of Function
Check EtCO2 levels and auscultate the lungs bilaterally to ensure that the tube is correctly placed in the trachea and that it functions properly.
Fix the tube with sutures (and taping).
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Piftalls and Complications
Pitfalls
Not Doing the Procedure
This is an emergency, life-saving procedure. Once decided that the procedure will happen, do not delay the procedure, and make sure to communicate the severity of the situation to the entire trauma team in order to receive appropriate assistance.
Wrong Entry Site
Make sure to carefully palpate the anatomical landmarks (thyroid cartilage, cricoid cartilage and the cricothyroid ligament), in order to correctly place the endotracheal tube. When possible, extend the neck in order to make palpation easier. Making the incision too cranial/caudal may cause difficulties in gaining access to the trachea.
Making the incision too caudal may cause damage to the thyroid isthmus which can lead to unnecessary bleeding and loss of visibility.
Inserting the Tube Too Deep
Another common mistake is placing the tube too deep, which can result in bronchial intubation. For the depth to be just right, advance the tube only until the cuff is completely inside. Avoid pushing it any further, although the part of the tube remaining outside may look surprisingly long.
Too Large Cannula
A tracheal cannula is usually too large a caliber for an emergency cricothyrotomy. Mostly, you will end up using a No. 6 standard endotracheal tube.
Time Constraints
At the time of decision-making, the patient may already be in extremis. Time is of the essence and immediate action is required. Circumstances may not be optimal with regards to patient positioning, lighting, background noise and other distracting elements. Therefore, practicing the procedure in advance is essential to ensure effective and timely intervention.
Not Adequately Controlling Bleeding
Bleeding can make the procedure more difficult and valuable time could be lost controlling the bleed. Loss of direct visibility can also lead to misplacement of the endotracheal tube. To reduce the bleeding that follows the incision, apply firm manual pressure on the lateral sides of the incision site. However, do not be intimidated by potentially bleeding skin edges or even anterior neck veins. These can be controlled with normal skin sutures, after tube placement.
Incorrect Incision and Depth
An incision made too deep could damage the posterior part of trachea and the adjacent esophagus. It is thus crucial to properly palpate the anatomical landmarks and to incise only deep enough to penetrate the anterior wall of trachea.
Complications
Bleeding From the Sternohyoid Muscles and/or Anterior Neck Veins
Making the incision too laterally may result in bleeding from the sternohyoid muscles and/or anterior neck veins. Make sure to palpate the landmarks before incising and apply firm pressure on the lateral edges of the incision in order to reduce bleeding while placing the tube.
Bronchial Intubation
Inserting the tube too deep may result in bronchial intubation. Avoid this by advancing the tube only until the cuff is completely inside, not any further.
Extra-Tracheally Placed Tube
The tube might be placed extra-tracheally if the EtCO2 level is not rising (indicating proper ventilation). Tube fixation and evaluation of function is crucial to ensure the tube is placed correctly.
Damage to the Esophagus
Incising too deeply, or dorsally, could result in damage to the esophagus. If this happens, appropriate treatment should happen when the patient's airway has been secured, ventilation ensured, and other similar life-threatening problems have been treated.
Aftercare
General Guidelines
Monitor ventilation function. If prolonged ventilator support is required, the emergency cricothyrotomy should be converted into a formal tracheostomy, as soon as it is safe for the patient.
When extubating a patient after an emergency cricothyrotomy, be prepared to close the wound surgically. There is hardly any soft tissue between the skin and the cricothyroid membrane. Failure to close the wound may lead to formation of fistulas.
Remember that cricothyrotomy is an emergency procedure, whereas conversion to a tracheostomy and extubation are not - the first has to be done immediately when needed, while the two latter should be performed electively, under optimized conditions and senior guidance.
FAQ
When is cricothyrotomy used?
Cricothyrotomy is an emergency procedure for securing an airway in a critically compromised patient, in scenarios where neither intubation nor ventilation can be performed.
What landmarks should be inspected and palpated before the skin incision?
Inspect and palpate the jugular notch, the cricoid and thyroid cartilages, and the cricothyroid membrane.
How should the bougie be advanced?
The bougie should be directed caudally and advanced as long as it slides in effortlessly. If advancing the bougie requires any force, you are in the wrong space.
How deep should the tube be inserted?
The tube should be advanced only until the cuff is completely inside the trachea. Placing the tube too deep could result in bronchial intubation.
What should be checked after attaching the tube to the ventilator?
Check EtCO2 levels and auscultate the lungs bilaterally to ensure that the tube is correctly placed in the trachea and that it functions properly.
What should be done if prolonged ventilator support is required after emergency cricothyrotomy?
If prolonged ventilator support is required, the emergency cricothyrotomy should be converted into a formal tracheostomy as soon as it is safe for the patient.
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