What are the indications for cricothyroidotomy (emergency tracheostomy) in the Emergency Department (ED)?

Indications for Cricothyroidotomy in the Emergency Department

Cricothyroidotomy is indicated in "can't intubate, can't oxygenate" (CICO) scenarios as the emergency front-of-neck airway technique of choice when all other airway management attempts have failed. 1

Primary Indications

• Failed Oxygenation Scenarios:

  • Cannot intubate AND cannot oxygenate via face mask or supraglottic airway device
  • Severe hypoxemia despite maximal conventional airway interventions
  • Imminent risk of hypoxic brain damage without immediate surgical airway

• Anatomical Barriers to Conventional Intubation:

  • Severe facial trauma preventing oral/nasal intubation
  • Massive oropharyngeal hemorrhage
  • Severe airway edema or obstruction (e.g., anaphylaxis, angioedema)
  • Distorted upper airway anatomy preventing conventional approaches

Procedural Decision Points

The 2018 British Journal of Anaesthesia guidelines recommend a clear, staged approach to CICO situations 2:

1. Priming for Front-of-Neck Airway (FONA):

   • Get FONA equipment to bedside after one failed intubation attempt
   • Open the FONA set after one failed attempt at facemask or supraglottic airway oxygenation
   • Immediately use the FONA set at CICO declaration

2. Technique Selection:

   • Scalpel cricothyroidotomy is the recommended default technique for CICO situations
   • Transtracheal jet ventilation (TTJV) via narrow-bore cannula is NOT recommended due to high failure rates, barotrauma risk, and complications 2

Preferred Technique

The Difficult Airway Society recommends a scalpel-bougie-tube cricothyroidotomy technique 2, 1:

1. Maximize neck extension
2. Make horizontal incision with wide scalpel blade (size 10 or 20) if cricothyroid membrane is palpable
3. If membrane is impalpable, make large vertical midline skin incision
4. Insert bougie as guide for 5.0-6.0 mm tracheal tube
5. Verify placement with waveform capnography

Important Considerations

• Cricothyroidotomy is preferred over emergency tracheostomy due to:

  • More superficial anatomical location
  • Fewer overlying structures
  • Reduced bleeding risk
  • Faster procedure time (critical in CICO scenarios) 1

• Ensure adequate neuromuscular blockade before performing cricothyroidotomy 2

• Ultrasound guidance can help identify the cricothyroid membrane in patients with distorted neck anatomy 1

• After successful cricothyroidotomy, convert to a definitive airway once the patient is stabilized 1

Contraindications and Cautions

• Relative contraindication: Patients with endotracheal intubation of more than seven days' duration 3
• Caution: Patients developing airway obstruction immediately following endotracheal extubation (higher risk of laryngeal stenosis) 3

Complications

Complications are relatively rare when performed properly. In multiple studies, cricothyroidotomy has been shown to be a safe and rapid means of obtaining an emergency airway 4. Potential complications include:

• Minor: Local wound infection, non-threatening hemorrhage 4
• Major (rare): Subglottic stenosis, tracheal stomal stenosis 5, 3

Remember that the risks of these complications are far outweighed by the immediate risk of death from hypoxia in a true CICO emergency.