EMERGENCY CRICOTHYROIDOTOMY

EMERGENCY CRICOTHYROIDOTOMY
• DEFINITION -
– An emergency surgical procedure where an
incision is made through the skin and cricothyroid
membrane which allows for the placement of an
endotracheal tube into the trachea when airway
control is not possible by other methods.
 INDICATIONS
• Obstructed Airway - obstructions within the
airway will usually prevent the passage of an
endotracheal tube or prevent the
establishment of a patent airway. Therefore,
a surgical airway distal to the obstruction is
required.
 INDICATIONS
• Congenital deformities of the oropharynx or
nasopharynx which inhibit or prevent
nasotracheal or orotracheal intubation
• Trauma to the head or neck which would
preclude the use of an ambu-bag,
oropharyngeal airway, nasopharyngeal
airway, or endotracheal tube insertion
 INDICATIONS
• Cervical Spine fractures, or highly suspect fractures
in a patient who requires an airway but whom
nasotracheal intubation is contraindicated.
Examples include:
– Nasal bone fractures
– Cribiform fractures
• The healthcare provider is unable to establish an
airway by any other means and this is the “last
resort.”
 ADVANTAGES OF EMERGENCY
CRICOTHYROIDOTOMY

• Provides a definitive airway for ventilating

the patient
• Can be performed quickly and has few
complications associated with the
procedure
 ADVANTAGES OF EMERGENCY
CRICOTHYROIDOTOMY

For an emergency cricothyroidotomy the laryngeal

prominence and cricoid cartilages are palpated and
entry is made through the median cricothyroid
ligament.
This procedure is preferable to a tracheotomy as
there are no large midline vessels in front of the
median cricothyroid ligament whereas there are in
front of the superior part of the trachea.
 CONTRAINDICATIONS
• Massive trauma to the larynx or cricoid cartilage:
– Damage to the affected structures will make it
impossible to perform the procedure properly
• If another means of establishing an airway has not
been performed. Examples include:
– Heimlich maneuver, nasotracheal or orotracheal
intubation
 COMPLICATIONS
– Major bleeding is caused by the laceration of
any major vessels (carotid artery or jugular
vein) within the neck.
» NOTE: Very Heavy bleeding is common and normal.
• Treatment: Same as minor bleeding. However, if
bleeding is not controlled with pressure, the vessel
may need to be ligated.
 COMPLICATIONS
• Esophageal Perforation or Tracheoesophageal Fistula
– Definition: The creation of a hole between the
esophagus and trachea
– Causes:
• Creating an incision too deep through the
cricoid membrane
• Forcing the endotracheal tube through the
cricoid membrane and into the esophagus
 COMPLICATIONS
– Treatment:
• Requires surgical repair of fistula or perforation.
 COMPLICATIONS
• Hemorrhage
– Is the most common complication
– Minor bleeding is caused by the laceration of
superficial capillaries in the skin tissue
• Note: The Thyroid Gland may extend into
the area of the cricothyroid membrane,
heavy bleeding can be experienced.
• Treatment: Direct pressure to control the
bleeding and then the application of a
simple pressure dressing
 COMPLICATIONS
• Subcutaneous Emphysema
– Definition: The presence of free air or gas within
the subcutaneous tissues

– Causes:
• Creating too wide of an incision will encourage
air entrapment under the subcutaneous tissue
• Air leaking out of the insertion site may get
trapped under the subcutaneous tissues
 COMPLICATIONS
– Treatment:
• No treatment is usually necessary.
Subcutaneous emphysema will usually
dissipate on its own accord within a few
days.
• However, placing a petroleum gauze
dressing around the incision / insertion site
will help reduce the incidence of
subcutaneous emphysema.
• Monitor the size of the subcutaneous
emphysema.
 DISADVANTAGES OF EMERGENCY
CRICOTHYROIDOTOMY

• Requires advanced training to properly

perform procedure.
• Bypasses the nares function of warming and
filtering the air.
• May increase respiratory resistance (due to
smaller tube size).
• Improper placement.
 ANATOMICAL LANDMARKS AND
STRUCTURES

• Trachea
• Thyroid Cartilage
• Cricoid Cartilage
• Cricothyroid Membrane
• Carotid Arteries
• Jugular Veins
• Esophagus
• Thyroid Gland
ANATOMICAL LANDMARKS AND
STRUCTURES-Closeup
Pharynx and Trachea in Detail
More Anatomy
Anterior view of the larynx to show the median
cricothyroid ligament.
1. Thyroid lamina.
2. Arch of cricoid cartilage.
3. Median cricothyroid ligament (cut here)
 Smallest Part of the Airway ???
• In Adults it is at the vocal cords
• In Infants and Children up to 8 it is the Cricoid
ring (cartilage), this is why uncuffed ET tubes
work in children.
Required Equipment for Emergency
Cricothyroidotomy
 Required Equipment
• #10 or 11 Scalpel • Curved Kelly Hemostat,
• Straight will work
Endotracheal Tube
• Ambu-bag
• 10 cc Syringe
• Sterile Dressing
• Stethoscope
• Vaseline / Petroleum
Gauze
• Betadine or Alcohol
Wipes
 Required Equipment (continued)
• Sterile or Clean Gloves
• Suture Material
• Suction Device
• Suture Scissors
• Tape
PROCEDURAL STEPS FOR EMERGENCY
CRICOTHYROIDOTOMY

• Determine that the patient’s ABC’s is in

jeopardy.
• Determine that the patient requires an
emergency cricothyroidotomy.
• Assemble required equipment, quickly.
• Do it. Don’t hesitate
PROCEDURAL STEPS FOR EMERGENCY
CRICOTHYROIDOTOMY

• Position the patient’s head/neck

– The patient is placed in a supine or semi-
recumbent position
– The neck is placed in a neutral position
 PROCEDURAL STEPS FOR
EMERGENCY CRICOTHYROIDOTOMY

• Palpate the thyroid and

cricoid cartilage for
orientation
– A - Cricoid Cartilage
– B - Cricothyroid
Membrane
– C - Incision Site
– D - Thyroid Cartilage
PROCEDURAL STEPS FOR EMERGENCY
CRICOTHYROIDOTOMY

• Locate the cricothyroid membrane

• Stabilize the thyroid cartilage using your non-
dominant hand
• Swab the incision site with alcohol or betadine
swabs
PROCEDURAL STEPS FOR EMERGENCY
CRICOTHYROIDOTOMY

• Make a vertical incision through the skin

approximately 2-5 cm (1 inch+) long over the
cricothyroid membrane

• Visualize the cricothyroid membrane

PROCEDURAL STEPS FOR EMERGENCY
CRICOTHYROIDOTOMY

• Discussion, Vertical or Horizontal incision?

– Vertical is best for emergencies, you will expose
the membrane guaranteed.
– Vertical does not heal well, there may be a scar
and some internal scaring/fibroids.
– You have to be alive to be inconvenienced by
the scar.
 PROCEDURAL STEPS FOR
EMERGENCY CRICOTHYROIDOTOMY

• Make a transverse
incision into the
cricothyroid
membrane
– DO NOT make the
incision more than
1/2 inch deep or
you may perforate
the esophagus
PROCEDURAL STEPS FOR EMERGENCY
CRICOTHYROIDOTOMY

• Insert the Curved Kelly Hemostat into the

incision and blunt dissect the incision (turn the
Curved Kelly Hemostat 90 degrees to open up
the incision)
• If you only have a straight hemostat, use it.
 PROCEDURAL STEPS FOR
EMERGENCY CRICOTHYROIDOTOMY

• Insert the endotracheal tube (adult 6.5

or smaller, Ped ? whatever will fit), into
the incision, directing the tube distally
down the trachea
PROCEDURAL STEPS FOR EMERGENCY
CRICOTHYROIDOTOMY

• Ventilate the patient with two breaths

– Check for proper placement of the endotracheal
tube with these first two ventilations by:
• Observing the chest rise and fall with each ventilation
• Auscultate for bilateral breath sounds
 Guideline for Breath Sounds
• Bilateral Breath Sounds present - the endotracheal
tube has been properly placed
– proper placement will cause both lungs to inflate
with each ventilation
• Bilaterally Absent Breath Sounds - the endotracheal
tube is not within the trachea and has probably been
placed within the esophagus.
– Remove the tube and attempt to reinsert into the
trachea
 Guidelines for Breath Sound
• Right main-stem placement is common.
• Breath Sounds in the Right Lung Field - the
endotracheal tube has been placed too far
down the bronchial tree and is in the right
mainstem bronchus.
– Pull back the tube 1/4 to 1/2 inch or until bilateral
breath sounds have been established
PROCEDURAL STEPS FOR EMERGENCY
CRICOTHYROIDOTOMY

• Auscultate over the epigastrium for gastric

sounds
– Placement of the endotracheal tube into the
stomach or esophagus will produce gurgling
sounds in the epigastric area with ventilations
PROCEDURAL STEPS FOR EMERGENCY
CRICOTHYROIDOTOMY

• Inflate the endotracheal tube’s cuff with 10

cc’s of air
– Inflation of the cuff serves two purposes:
• Holds the endotracheal tube in place
• Acts as a barrier and prevents fluids from entering the
lungs
 PROCEDURAL STEPS FOR
EMERGENCY CRICOTHYROIDOTOMY
• Apply petroleum gauze
dressing to insertion site
• Apply a dry, sterile dressing
to the insertion site
• Tape around the tube then
neck, sutures can be done
later
PROCEDURAL STEPS FOR EMERGENCY
CRICOTHYROIDOTOMY

• Continue to ventilate the patient (1 breath

every 5 seconds) and suction as necessary.
– Loving Gentle Squeeze 2 in, 3 out.

• Continue to monitor the patient for changes