Airway - Cricothyroidotomy (surgical)

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We outline a simple scalpel-finger-bougie approach

Regular physical practice of your chosen method is recommended

Unfamiliar equipment is best avoided in an emergency

Indications

Inability to oxygenate and ventilate by other means (BVM, LMA, ETT)

and

Age ≥10 years old

Contraindications (absolute in bold)

Tracheal rupture or transection

Laryngeal fracture

Alternatives

Bag valve mask ventilation

Laryngeal mask airway

Intubation

Needle cricothyroidotomy and jet insufflation

Tracheostomy

Informed consent

Medical emergency

Consent is not required if the patient lacks capacity or is unable to consent

Brief verbal discussion is recommended if the situation allows

Potential complications

Failure (false passage with surgical emphysema, unable to identify anatomy)

Bleeding (with potential aspiration)

Coughing

Neurovascular, oesophageal and laryngeal injury (cord, cartilage, tracheal)

Infection

Procedural hygiene

Standard precautions

PPE: non-sterile gloves, aprons, surgical mask and protective eyewear or face shield

Area

Resuscitation bay

Staff

Procedural clinician

At least one assistant

Equipment

Scalpel

Bougie

Size 6.0 endotracheal tube and lubricant

10ml syringe

Stay suture

Tape for endotracheal tube

Hard collar

Positioning

Patient supine with neck extended and held midline by assistant

Procedural clinician lateral to patient with dominant hand towards head (patient’s left side if right-handed)

Locate the cricothyroid membrane by palpating the prominence of the thyroid cartilage and moving the finger inferiorly into the depression between the thyroid and cricoid cartilages.

Consider marking membrane and infiltrating with lignocaine and adrenaline prior to induction for predicted difficult intubations. Be aware the mark will move superiorly if the head is extended.

Medication

5ml lignocaine 1% with adrenaline 1:100,000 (prior to induction only)

Sequence (if able to palpate cricothyroid membrane)

Brief team ‘I’m performing a surgical airway now’ and allocate roles

Remove pillow and direct assistant to support head and neck extended in the midline

Direct additional assistant to attempt ventilation with a laryngeal mask airway

Identify cricothyroid membrane

Stabilise larynx with thumb and middle finger of non-dominant hand ‘laryngeal handshake’

Palpate cricothyroid membrane with index finger

Make a 15mm transverse incision with dominant hand through cricothyroid membrane

Remove scalpel and place finger into trachea, palpating posterior wall

Insert bougie under pulp of inserted finger

Advance bougie approximately 15cm (early hold up indicates false passage)

Railroad a lubricated size 6.0 ETT over bougie, with rotation on insertion until cuff if just inside the trachea

Remove bougie, inflate the cuff and confirm position with ETCO2 trace on ventilation

Secure with tape and allocate an assistant to hold the ETT until a definitive airway is placed

Consider a stay suture placed close to the skin incision, wrapped tightly around the ETT and tied securely

Consider placing a hard collar to maintain neck position

Use pressure to control bleeding after you have secured your tube

Sequence (unable to palpate cricothyroid membrane)

Make an 8cm midline incision, starting two finger-widths above sternal notch

Blunt dissection with fingers of both hands down to larynx or trachea (palpation not visual)

Laryngeal handshake when structures identified

Transverse incision as above either in trachea or cricothyroid membrane if identified

Post-procedure care

Urgent anaesthetic and ENT assessment for definitive airway

Dedicated team member continues to hold secured ETT until definitive airway placed

Provide ongoing sedation and paralysis

Chest X-ray to confirm placement

Document after definitive airway placed (completion, complications)

Tips

The most difficult part of procedure is making the decision to proceed to surgical airway

This procedure is high risk for aerosolised spray of blood and sharps injury

Passage of the bougie against resistance can create a long false passage with surprising ease

Tracheal rings are not always felt on the bougie with correct placement

Observe the first test ventilation closely for surgical emphysema suggesting false passage

Ultrasound may be useful to identify the cricothyroid membrane prior to induction in high-risk patients

Discussion

Asepsis is not required for an emergency airway. The risk of infection is insignificant compared to the risk of further hypoxia in a can’t ventilate situation. If time allows for the identification and marking of the skin over the cricothyroid membrane prior to a high-risk intubation, then antisepsis might also be applied at this time.

Heavy bleeding is expected and should be ignored while placing the airway. Relying on palpation to complete the surgical airway. Use pressure to control bleeding after you have secured your tube.

We do not recommend Seldinger can’t intubate can’t oxygenate kits. Available evidence shows these are slower than open cricothyroidotomy and have higher failure rates.

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

Greater Sydney Area Helicopter Emergency Service

CareFlight

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

Higgs A, McGrath BA, Goddard C, et al. Guidelines for the management of tracheal intubation in critically ill adults. Br J Anaesth. 2018;120(2):323‐352. doi:10.1016/j.bja.2017.10.021

Frerk C, Mitchell VS, McNarry AF, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015;115(6):827‐848. doi:10.1093/bja/aev371

Greater Sydney Area Helicopter Emergency Medical Service: Anaesthesia manual 2018

Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges' clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.

Dunn RJ, Borland M, O'Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

Walls RM, Murphy, MF. Manual of emergency airway management. (4th ed). Philadelphia PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2012.

Begley JL, Butson B, Kwa P. The emergency surgical airway. Emerg Med Australas. 2017;29(5):570‐575. doi:10.1111/1742-6723.12850

Sakles JC. Emergency cricothyrotomy (cricothyroidotomy). In: UpToDate. Waltham (MA): UpToDate. 2020 Apr 23: Retrieved May 2020. Available from: https://www.uptodate.com/contents/emergency-cricothyrotomy-cricothyroidotomy

Chrimes N. The vortex approach to the difficult airway. 2016. [Cited Feb 2017.] Available from: http://vortexapproach.org

Paix BR, Griggs WM. Emergency surgical cricothyroidotomy: 24 successful cases leading to a simple 'scalpel-finger-tube' method. Emerg Med Australas. 2012;24(1):23‐30. doi:10.1111/j.1742-6723.2011.01510.x

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