Cricothyrotomy

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Background
Precautions: Difficult Cricothyrotomy
Protocol: Preparation (Cricothyrotomy Tray)
Protocol: Double-Setup with the CriCon Technique
Protocol: No-Drop Technique
Management: Post-Cricothyrotomy
Resources
References
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II. Background

Cicothyrotomy is a life-saving definitive tool on the spectrum of airway management interventions
1. Indicated in a "Can't Intubate, Can't Oxygenate" (CICO) scenario
2. Indicated when other Advanced Airways have been attempted without success
3. Cricothyrotomy should not be considered a failure of airway management

III. Precautions: Difficult Cricothyrotomy

Mnemonic: SHORT
1. Surgery (with midline neck scar)
2. Hematoma
3. Obesity (or other impediments to access, such as C-Collar)
4. Radiation Therapy history
5. Trauma or Tumor (with distorted Laryngeal Anatomy)
Mnemonic: SMART
1. Surgery (with midline neck scar)
2. Mass (Hematoma, abscess or other mass interfering with Cricothyrotomy path)
3. Access (C-Collar or brace) or Anatomy (Obesity, redundant tissue)
4. Radiation Therapy history to neck
5. Tumor (encroaching on the airway)

IV. Protocol: Preparation (Cricothyrotomy Tray)

Tracheal Hook
Trousseau Dilator
Scalpel (#11 Blade)
Tracheostomy tube (cuffed, unfenestrated, #4)
1. Test cuff prior to insertion
Miscellaneous items
1. Gauze 4x4
2. Hemostats (small, 2)
3. Surgical drape
4. Elastic Bougie

V. Protocol: Double-Setup with the CriCon Technique

Background
1. Dr. Scott Weingart on emcrit.org likens Cricothyrotomy preparedness (CriCon) to the old military DefCon system
Indications
1. Assign a Cri-Con level to and prepare for every Advanced Airway placement
2. Employ a second airway provider to stand-by at the neck for emergency Cricothyrotomy
Levels
1. Green (Cri-Con 5): All patients undergoing intubation
  1. Have Cricothyrotomy kit available if needed (check stock)
2. Yellow (Cri-Con 4): Anticipated Difficult Airway
  1. Mark 1.5 cm vertical incision line with skin marker from Thyroid cartilage to cricoid (see below)
  2. Move Cricothyrotomy kit to bedside
3. Red (Cri-Con 3-2-1): Anticipated Failed Airway with no reserve for repeat intubation attempt
  1. Prepare the neck with Hibiclens or Betadine
    1. Open the Cricothyrotomy kit
    2. Scalpel is ready to make incision
  2. Make vertical incision
    1. Feel the cricothyroid membrane
    2. Perform circothyrotomy
    3. See No-Drop technique as below
References
1. Weingart et al in Herbert (2016) EM:Rap 16(11): 4-5
2. EMCrit Blog (Scott Weingart, MD)
  1. http://emcrit.org/wee/bougie-prepass-and-criccon/

VI. Protocol: No-Drop Technique

Identify the landmarks
1. Thyroid cartilage
2. Cricothyroid membrane
3. Cricoid cartilage
  1. Place fingers at sternal notch
  2. Slide fingers up, in midline, over the top of each tracheal ring
  3. Cricoid cartilage will be the first significant bump palpated
Mark the incision line with skin marker
1. Draw vertical line down midline from mid-Thyroid cartilage to cricoid cartilage
2. Consider Ultrasound (linear probe) to identify landmarks when soft tissue obscures the cricothyroid membrane and airway
Prepare the skin
1. Antiseptic solution (e.g. Hibiclens, Betadine)
2. Lidocaine 1% with Epinephrine infiltrated into skin and subcutaneous tissue down to cricothyroid membrane
  1. Even in a sedated patient, the Epinephrine may reduce bleeding
Immobilize the Larynx
1. Use "Laryngeal Handshake" method (Levitan, see EM-Crit surgical airway link below)
2. Hold Thyroid cartilage between thumb and middle finger
3. Slide down the Thyroid cartilage with fingers on either side
4. Place index finger on cricothyroid membrane (between the thumb and middle finger)
Vertical Skin Incision (superficial)
1. Make superficial vertical 2 cm incision
2. Incise in midline from mid-Thyroid cartilage to cricoid ring
3. Insert index finger to palpate cricothyroid membrane
4. Some providers skip the vertical incision if they can easily identify the cricothyroid membrane
  1. They move straight to making a horizontal incision below
  2. Reduces bleeding and time to "cut to air"
  3. However, greater risk of straying off the midline
Horizontal cricothyroid membrane incision
2. Make horizontal incision at lower aspect of membrane (avoids vessels at top of membrane)
  1. Blood and soft tissue shifting will quickly obscure landmarks (and will spray blood)
  2. Posterior aspect of cricoid cartilage serves as a long backstop
    1. Prevents knife from penetrating deep structures
3. Technique: Make stab incision through membrane
  1. Cut to one direction, rotate blade 180 degrees, and cut opposite direction
  2. Hole must be wide enough to fit a finger, bougie and tube
Immediately place finger or Elastic Bougie through incision into airway to hold position open
1. Option 1: Bougie and 6.0 or 6.5 ET Tube rapid technique (scalpel-finger-tube)
  1. Immediately move to 6.0 or 6.5 Endotracheal Tube over Elastic Bougie (without inserting hook)
  2. http://emcrit.org/wee/real-surgical-airway/
  3. http://emcrit.org/wp-content/uploads/2014/08/EMA-Scalpel-FInger-Bougie.pdf
2. Option 2: Tracheal hook and dilator
  1. Insert tracheal hook
    1. Insert through hook incision
    2. Rotate hook so it retracts the upper membrane in cephalad direction
  2. Insert Trousseau dilator
    1. Dilator is inserted a short distance
    2. Spread the membrane vertically
Insert Tracheostomy tube
1. Consider first inserting Elastic Bougie as guidewire for the Tracheostomy tube (see above)
2. Consider 6.0 or 6.5 Endotracheal Tube in place of standard Shiley Tracheostomy tube
  1. Use an ET Tube that is shortened to 11 cm (alternatively, 6.0 Portex cuffed trach tube may be used)
  2. ET Tube is inserted only until balloon is completely inside incision, then inflated
  3. ET Tube is more easily inserted and managed
    1. Less interlocking parts than Shiley
    2. Shiley diameters are not consistent and may not allow Gum Elastic Bougie passage
3. Insert Tracheostomy tube gently (avoid creating a false passage)
  1. Rotate so tube is directed towards Bronchi
  2. Remove dilator and hook (if used)
  3. Inflate Tracheostomy cuff
Confirm tube placement
1. Auscultate lung fields
2. CO2 Detector or Capnography (or consider esophageal detector in Cardiac Arrest)
3. Observe for subcutaneous Emphysema
  1. Suggests paratracheal insertion via false passage
  2. A Nasogastric Tube or Elastic Bougie inserted into tube will meet significant resistance if tube is mal-placed
Completion
1. Obtain Chest XRay
2. Secure tube in place
  1. Tape (2 inch) split in half at each end and each half wrapped around tube (and other part of tape to chest)
  2. Respiratory therapy may have more secure ways to fix the tube in position

VII. Management: Post-Cricothyrotomy

Consult pulmonology or Anesthesia for controlled attempt at intubation from above (e.g. under bronchoscopy)
Consult otolaryngology for further management of Cricothyrotomy site

VIII. Resources

EM Crit: Surgical Airway (Scott Weingart)
1. http://emcrit.org/podcasts/surgical-airway/

IX. References

Brown (2022) Walls Manual of Emergency Airway Management, LWW
Levitan (2013) Practical Airway Management Course, Baltimore
Majoewsky (2012) EM:Rap-C3 2(9): 6
Walls (2008) Emergency Airway Management, Lippincott, Philadelphia, p. 193-220

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