Cricothyrotomy

Pronunciation
Other names
Medical specialty
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Complications
Approach
Types
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Larynx external Cricothyrotomy

Cricothyrotomy kit

Cricothyrotomy, also known as cricothyroidotomy, thyrocricotomy, inferior laryngotomy, intercricothyrotomy, or emergency airway puncture, is a life-saving emergency procedure used to secure an airway when other methods, such as endotracheal intubation, are impossible or contraindicated. This involves making an incision through the skin and cricothyroid membrane to establish a temporary airway for oxygen exchange.

Cricothyrotomy is faster and easier to perform than a tracheotomy and does not require manipulation of the cervical spine, making it the preferred emergency airway intervention in situations like trauma, airway obstruction, or failed intubation attempts.

Indications

A cricothyrotomy is indicated when conventional airway management techniques fail or cannot be performed. Some key indications include:

• Severe airway obstruction – Caused by trauma, swelling, burns, anaphylaxis, or foreign body aspiration.
• Failed orotracheal or nasotracheal intubation – Particularly in difficult airway cases.
• Massive facial trauma – When the oral and nasal passages are compromised.
• Severe angioedema – Rapid swelling of the larynx, tongue, or pharynx, making intubation impossible.
• Inability to ventilate – If standard airway management fails to maintain adequate oxygen saturation (SpO2 >90%).
• Smoke inhalation injury – Causing laryngeal edema and airway obstruction.
• Glottic or supraglottic mass – Tumors or lesions preventing normal intubation.

Contraindications

While a cricothyrotomy is a life-saving intervention, there are some relative contraindications, including:

• Inability to identify the cricothyroid membrane – Due to obesity, trauma, or anatomical anomalies.
• Severe neck infection or tumors – Making the procedure more difficult or increasing the risk of complications.
• Tracheal injury or transection – If the trachea is completely disrupted, an alternative approach may be required.
• Children under 12 years old – Needle cricothyrotomy is preferred in pediatric patients due to a smaller airway.

Procedure

The procedure involves a surgical incision or a needle puncture through the cricothyroid membrane. There are two main methods:

1. Surgical Cricothyrotomy (Preferred for Adults) 1. Identify the cricothyroid membrane – Located between the thyroid cartilage (Adam’s apple) and cricoid cartilage. 2. Clean the area – Using antiseptic solution. 3. Make a vertical incision – 1–2 cm over the cricothyroid membrane. 4. Make a transverse incision – Directly through the membrane. 5. Insert a tracheostomy or endotracheal tube (6.0–7.0 mm diameter). 6. Secure the tube and verify bilateral lung expansion with auscultation.

2. Needle Cricothyrotomy (Preferred for Children) 1. Insert a large-bore needle (10–14 gauge) into the cricothyroid membrane. 2. Confirm placement by aspirating air. 3. Attach a high-pressure oxygen source (jet ventilation). 4. Monitor for adequate ventilation.

Post-Procedure Management

Once a cricothyrotomy is performed, continuous monitoring and conversion to a definitive airway (such as a tracheostomy) are necessary. Management includes:

• Securing the tube to prevent accidental displacement.
• Monitoring for complications such as bleeding, infection, or subcutaneous emphysema.
• Oxygenation and ventilation using a mechanical ventilator if needed.
• Conversion to tracheostomy within 24–48 hours for long-term airway management.

Complications

Although life-saving, cricothyrotomy carries potential risks:

• Bleeding – Damage to thyroid vessels or carotid arteries.
• Subcutaneous emphysema – Air trapping in tissues due to improper tube placement.
• Tracheal stenosis – Narrowing of the airway if prolonged use occurs.
• Aspiration – If protective airway reflexes are lost.
• Accidental misplacement – Leading to inadequate ventilation.

Training and Simulation

Cricothyrotomy is rarely performed in clinical settings, making hands-on training and simulation crucial for emergency providers. Medical mannequins, animal models, and cadaver labs are used for training. Companies such as Your Design Medical, Simulaids, and Simulab produce cricothyrotomy trainers to simulate real-life conditions.

Needle vs. Surgical Cricothyrotomy

| Feature | Needle Cricothyrotomy | Surgical Cricothyrotomy | |--------------------|------------------------|------------------------| | Preferred in | Pediatric patients (<12 years) | Adults | | Procedure | Catheter over needle | Scalpel and tube | | Ventilation | Jet ventilation needed | Standard ventilation | | Complications | Limited airflow | Higher bleeding risk | | Conversion | Must convert to tracheostomy | Can be maintained longer |

Cricothyrotomy in Popular Media

Cricothyrotomy is often depicted in movies, TV shows, and books. While these portrayals sometimes exaggerate the procedure, they have helped raise awareness about emergency airway management.

• M*A*S*H – Father Mulcahy performs a makeshift cricothyrotomy using a knife and an eye dropper.
• Grey’s Anatomy (TV series) – Multiple characters perform emergency cricothyrotomies in high-stress scenarios.
• ER – Dr. Kerry Weaver performs an emergency cricothyrotomy with a kitchen knife and a drinking straw.
• Anaconda – A character undergoes an emergency cricothyrotomy after being stung by a poisonous wasp.
• Inside Combat Rescue (National Geographic) – A real-life cricothyrotomy is performed mid-flight in a combat zone.

See Also

• Laryngotomy
• Tracheotomy
• Emergency airway management
• Rapid sequence intubation
• Endotracheal intubation

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