Chapter 5. Cricothyrotomy

• • Patients who cannot be adequately oxygenated or ventilated using bag-mask ventilation.

  • Patients in whom it is impossible to establish an airway via oral or nasal endotracheal intubation due to any of the following:

  • • Bleeding from upper airway structures.

    • Massive emesis.

    • Masseter spasm.

    • Spasm of the larynx or pharynx.

    • Laryngeal stenosis.

    • Structural deformities of the upper airway.

  • To avoid delay in airway control in patients with upper airway obstruction, thus preventing or shortening periods of anoxia.

  • Patients with maxillofacial trauma, laryngeal trauma (except for tracheal transection), and unstable cervical spine fractures to minimize movement of the neck.

  • An elective situation when a patient is undergoing surgery of the head, face, or neck.

Absolute

• • Cricothyrotomy should not be performed in any patient who can quickly and easily be intubated using nonsurgical means.

  • Patients with a fractured or significantly damaged larynx.

  • Patients with tracheal transection.

  • • The cervical fascia may be tenuously holding the airway together.

    • The incision required to perform a cricothyrotomy may transect the fascia causing the distal airway to retract into the mediastinum.

    • In such cases, tracheostomy is the preferred method for controlling the airway.

Relative

• • Coagulopathy.

  • Preexisting infection.

  • Significant neck distortion.

  • Massive neck edema.

  • In children younger than 5 years, needle cricothyrotomy with transtracheal jet ventilation is recommended due to the difficulty of performing a surgical cricothyrotomy. (Some clinicians recommend transtracheal jet ventilation for children younger than 12 years.)

  • Establishing an airway should supersede any relative contraindication in a patient in extremis.

Surgical Cricothyrotomy

• • Scalpel.

  • Tracheal dilator (Trousseau dilator) or spreader or hemostat.

  • Appropriate size tracheostomy or endotracheal tube.

  • 25-gauge needle and syringe with 1% lidocaine (for local anesthesia).

  • Preparation solution (either 2% chlorhexidine-based preparation in patients older than 2 months of age or 10% povidone-iodine).

  • Sterile gauze pads.

  • Ties for tracheostomy tube.

  • Oxygen source and suction.

  • Bag-valve device.

Needle Cricothyrotomy

• • 12- or 14-gauge needle or over-the-needle catheter.

  • 5- or 10-mL syringe.

  • High-pressure tubing.

  • Stopcock.

  • High-pressure oxygen source at 50 psi.

  • • If a high-pressure oxygen source is not available, use a bag-valve device with the proximal connector of an 8.0 endotracheal tube and 3-mL syringe or the proximal connector of a 3.0 endotracheal tube.

• • Remember, the thyroid gland lies inferior to the larynx. Therefore, if the thyroid gland is visualized, the incision should be extended cranially, toward the larynx.

  • After making an incision through the cricoid membrane, it may be necessary to lift and hold the larynx anteriorly with a tracheal hook in order to avoid posterior displacement of the larynx.

  • If needle cricothyrotomy is performed and there is no pressurized oxygen source available, the patient ...