Procedure
Cricothyrotomy
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Cricothyrotomy
, CriCon, Emergency Tracheostomy Via Cricothyroid Membrane
See Also
Advanced Airway
Rapid Sequence Intubation
Endotracheal Intubation Preparation
Endotracheal Tube
Endotracheal Intubation Preoxygenation
(and
Apneic Oxygenation
)
Direct Laryngoscope
Video Laryngoscope
Endotracheal Intubation
Extraglottic Device
(e.g.
Laryngeal Mask Airway
or LMA)
Tactile Orotracheal Intubation
(
Digital Intubation
)
Nasotracheal Intubation
Needle Cricothyrotomy
Background
Cicothyrotomy is a life-saving definitive tool on the spectrum of airway management interventions
Indicated in a "Can't Intubate, Can't Oxygenate" (CICO) scenario
Indicated when other
Advanced Airway
s have been attempted without success
Cricothyrotomy should not be considered a failure of airway management
Precautions
Difficult Cricothyrotomy (Mnemonic: SHORT)
Surgery (with midline neck scar)
Hematoma
Obesity
Radiation Therapy
history
Trauma
(with distorted
Laryngeal Anatomy
)
Protocol
Preparation (Cricothyrotomy Tray)
Tracheal Hook
Trousseau Dilator
Scalpel (#11 Blade)
Tracheostomy
tube (cuffed, unfenestrated, #4)
Test cuff prior to insertion
Miscellaneous items
Gauze 4x4
Hemostats (small, 2)
Surgical drape
Elastic Bougie
Protocol
Double-Setup with the CriCon Technique
Background
Dr. Scott Weingart on emcrit.org likens Cricothyrotomy preparedness (CriCon) to the old military DefCon system
Indications
Assign a Cri-Con level to and prepare for every
Advanced Airway
placement
Employ a second airway provider to stand-by at the neck for emergency Cricothyrotomy
Levels
Green (Cri-Con 5): All patients undergoing intubation
Have Cricothyrotomy kit available if needed (check stock)
Yellow (Cri-Con 4): Anticipated Difficult Airway
Mark 1.5 cm vertical incision line with skin marker from
Thyroid
cartilage to cricoid (see below)
Move Cricothyrotomy kit to bedside
Red (Cri-Con 3-2-1): Anticipated Failed Airway with no reserve for repeat intubation attempt
Prepare the neck with
Hibiclens
or
Betadine
Open the Cricothyrotomy kit
Scalpel is ready to make incision
Make vertical incision
Feel the cricothyroid membrane
Perform circothyrotomy
See No-Drop technique as below
References
Weingart et al in Herbert (2016) EM:Rap 16(11): 4-5
EMCrit Blog (Scott Weingart, MD)
http://emcrit.org/wee/bougie-prepass-and-criccon/
Protocol
No-Drop Technique
Identify the landmarks
Thyroid
cartilage
Cricothyroid membrane
Cricoid cartilage
Place fingers at sternal notch
Slide fingers up, in midline, over the top of each tracheal ring
Cricoid cartilage will be the first significant bump palpated
Mark the incision line with skin marker
Draw vertical line down midline from mid-
Thyroid
cartilage to cricoid cartilage
Consider
Ultrasound
(linear probe) to identify landmarks when soft tissue obscures the cricothyroid membrane and airway
Prepare the skin
Antiseptic solution (e.g.
Hibiclens
,
Betadine
)
Lidocaine
1% with
Epinephrine
infiltrated into skin and subcutaneous tissue down to cricothyroid membrane
Even in a sedated patient, the
Epinephrine
may reduce bleeding
Immobilize the
Larynx
Use "Laryngeal Handshake" method (Levitan, see EM-Crit surgical airway link below)
Hold
Thyroid
cartilage between thumb and middle finger
Slide down the
Thyroid
cartilage with fingers on either side
Place index finger on cricothyroid membrane (between the thumb and middle finger)
Vertical Skin Incision (superficial)
Make superficial vertical 2 cm incision
Incise in midline from mid-
Thyroid
cartilage to cricoid ring
Insert index finger to palpate cricothyroid membrane
Some providers skip the vertical incision if they can easily identify the cricothyroid membrane
They move straight to making a horizontal incision below
Reduces bleeding and time to "cut to air"
However, greater risk of straying off the midline
Horizontal cricothyroid membrane incision
Make horizontal incision at lower aspect of membrane (avoids vessels at top of membrane)
Blood and soft tissue shifting will quickly obscure landmarks (and will spray blood)
Posterior aspect of cricoid cartilage serves as a long backstop
Prevents knife from penetrating deep structures
Technique: Make stab incision through membrane
Cut to one direction, rotate blade 180 degrees, and cut opposite direction
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
Option 1: Bougie and 6.0 or 6.5
ET Tube
rapid technique (scalpel-finger-tube)
Immediately move to 6.0 or 6.5
Endotracheal Tube
over
Elastic Bougie
(without inserting hook)
http://emcrit.org/wee/real-surgical-airway/
http://emcrit.org/wp-content/uploads/2014/08/EMA-Scalpel-FInger-Bougie.pdf
Option 2: Tracheal hook and dilator
Insert tracheal hook
Insert through hook incision
Rotate hook so it retracts the upper membrane in cephalad direction
Insert Trousseau dilator
Dilator is inserted a short distance
Spread the membrane vertically
Insert
Tracheostomy
tube
Consider first inserting
Elastic Bougie
as guidewire for the
Tracheostomy
tube (see above)
Consider 6.0 or 6.5
Endotracheal Tube
in place of standard Shiley
Tracheostomy
tube
Use an
ET Tube
that is shortened to 11 cm (alternatively, 6.0 Portex cuffed trach tube may be used)
ET Tube
is inserted only until balloon is completely inside incision, then inflated
ET Tube
is more easily inserted and managed
Less interlocking parts than Shiley
Shiley diameters are not consistent and may not allow
Gum Elastic Bougie
passage
Insert
Tracheostomy
tube gently (avoid creating a false passage)
Rotate so tube is directed towards
Bronchi
Remove dilator and hook (if used)
Inflate
Tracheostomy
cuff
Confirm tube placement
Auscultate lung fields
CO2 Detector or
Capnography
(or consider esophageal detector in
Cardiac Arrest
)
Observe for subcutaneous
Emphysema
Suggests paratracheal insertion via false passage
A
Nasogastric Tube
or
Elastic Bougie
inserted into tube will meet significant resistance if tube is mal-placed
Completion
Obtain
Chest XRay
Secure tube in place
Tape (2 inch) split in half at each end and each half wrapped around tube (and other part of tape to chest)
Respiratory therapy may have more secure ways to fix the tube in position
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
Resources
EM Crit: Surgical Airway (Scott Weingart)
http://emcrit.org/podcasts/surgical-airway/
References
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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