Background: Cricothyrotomy is a high acuity low occurrence (HALO) procedure that is time critical. It is the common final step in the cannot intubate cannot oxygenate (CICO) and/or cannot intubate cannot ventilate (CICV) situation. Due to the time critical nature of the procedure, any approach must include three facets:
- Be as simple and rapid as possible
- No special equipment required
- High success and low complication rate
[embedyt] https://www.youtube.com/watch?v=isP9nH3Nitk[/embedyt]
14 minute video on anatomy and procedure of bougie-assisted cricothyrotomy
Hardest Part of the Procedure:
- Making the decision to cut
- Cricothyrotomy typically performed too late to prevent poor outcome
- The time taken to act
- The time taken to prepare
- Important to remember there is no absolute contraindications to this procedure
Equipment Needed:
- 10 or 11 blade scalpel
- Bougie
- 6.0 – 6.5 endotracheal tube
Anatomy You Need to Know:
- Thyroid Cartilage
- Cricothyroid Membrane/Ligament
- In adults this is 9 to 19mm horizontally & 9 to 20mm vertically)
- Cricoid Cartilage
- Trachea
Laryngeal Handshake:
- Palpate thyroid cartilage
- Palpate cricoid cartilage
- Cricothyroid membrane/ligament will be a slight depression between the two
The Procedure:
- Vertical incision
- Place finger into incision and palpate ligament prior to stab incision
- Horizontal incision (stab blade into membrane then drag, flip, drag without removing scalpel)
- Want to make horizontal incision in lower half of the cricothyroid membrane
- Potentially avoids cricothyroid arteries and vocal cords
- Remove the scalpel and insert the tip of the finger into the incision
- Confirms that the incision has penetrated into the laryngeal lumen
- Confirms the incision is large enough to accommodate an endotracheal tube
- Bougie slides in right behind finger
- Endotracheal tube slide over bougie
- Cricothyroid membrane is located below vocal cords therefore avoid feeding endotracheal tube too far in (Feed until cuff disappears into tracheal lumen)
Practice Practice Practice:
- Training should be repeated at least once a month to maintain fidelity with the procedure
- Can use 3D printed models
- Electrical Tape = Membrane
- Foam Tape = Skin
References:
- Sorbello M et al. Front-of-Neck Access and Bougie Trapping. Anaesthesia 2018. PMID: 30132808
- Paix BR et al. Emergency Surgical Cricothyroidotomy: 24 Successful Cases Leading to a Simple ‘Scalpel-Finger-Tube’ Method. Emerg Med Australas 2012. PMID: 22313556
- Langvad S et al. Emergency Cricothyrotomy – A Systematic Review. Scand J Trauma Resusc Emerg Med 2013. PMID: 23725520
For More Thoughts on This Topic:
- EMCrit: Podcast 131 – Cricothyrotomy – Cut to Air – Emergency Surgical Airway
- EMCrit: Mind Blowing Cricothyrotomy Video
- LITFL: Surgical Cricothyroidotomy
- EMCrit: Wanted Dead or Alive, Your FONA Experiences
Post Peer Reviewed By: Anand Swaminathan, MD (Twitter: @EMSwami)
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