From the Guidelines
Cricothyroidotomy is indicated in emergency airway management situations when other methods of securing an airway have failed or are contraindicated, and should be performed using a scalpel-bougie-tube technique as recommended by the most recent guidelines 1. The procedure is life-saving because it bypasses upper airway obstructions and provides immediate oxygen to prevent hypoxic brain injury and death. Key steps in the procedure include:
- Making a horizontal incision with a wide scalpel blade for those with a palpable cricothyroid membrane, or an initial large vertical midline skin incision if the cricothyroid membrane is impalpable
- Insertion of a bougie as a guide for a 5.0-6.0 mm tracheal tube
- Ensuring the smaller tracheal tube size fits over the type of bougie used in the unit This technique is preferred over tracheostomy in emergency situations because the cricothyroid membrane is more superficial, has fewer blood vessels, and is easier to identify, allowing for faster airway access when seconds matter, as supported by the Difficult Airway Society guidelines 1 and the British Journal of Anaesthesia guidelines 1. Specific indications for cricothyroidotomy include:
- Severe facial trauma
- Massive oropharyngeal bleeding
- Severe oropharyngeal edema
- Laryngeal trauma
- Complete upper airway obstruction from foreign bodies, angioedema, or other causes It is essential to note that high pressure source transtracheal ventilation via a narrow bore cannula, also known as transtracheal jet ventilation (TTJV), is not recommended due to its high risk of failure and complications, as highlighted in the British Journal of Anaesthesia guidelines 1.
From the Research
Cricothyroid Indication
- Cricothyroidotomy is considered when emergent airway access is needed and translaryngeal intubation is not possible 2
- It is also recommended in "Can't Intubate, Can't Oxygenate" (CICO) situations as a potential life-saving treatment 3, 4
- The procedure can be used in trauma patients with unsuccessful endotracheal intubation 5
- Cricothyroidotomy can be used electively in respiratory problems requiring tracheotomy, with a low complication rate of 6.1% 6
Comparison with Tracheostomy
- Cricothyroidotomy has fewer late complications compared to tracheostomy 3
- However, cricothyroidotomies performed in emergent situations should be converted to tracheostomies in a timely fashion due to insufficient evidence for long-term use 3
- Cricothyroidotomy has a shorter operating time and less bleeding compared to tracheostomy and percutaneous dilatational tracheostomy 4
Procedure and Management
- The procedure involves making a transverse incision through the superficial cricothyroid membrane 2
- Accidental tube displacement within 5 days of surgery is a potential complication of tracheotomy, which can be prevented with careful management and expert nursing support 2
- Cricothyroidotomy can be performed at the bedside with no additional complications 6