Procedure - Surgical Cricothyrotomy

 Introduction

A cricothyrotomy is an emergency airway technique used in certain situations that involves an incision through the skin and cricothyroid membrane allowing the passage of an endotracheal tube or Shiley Tracheostomy appliance to provide an unobstructed airway that one may use for ventilation and oxygenation.

Indications (FAST)

Foreign body

Airway obstruction

Swelling (Angioedema, Anaphylaxis, Fire or Chemical Burns)

Trauma of the face, which prevents oral and nasal tracheal intubation

Contraindications

Anatomical abnormality making landmarking of the cricothyroid membrane difficult (Tumor, abscess, congenital abnormality, vascular abnormality (i.e. large hemangioma).

Procedure

 Landmark

Technique 1: Identify the Tracheal Prominence, then the Tracheal membrane above, then the cricothyroid membrane below the prominence (Video: Landmarking & Landmarking - Cross-section)

 

 

Technique 2: Identify the Sternal Notch, place your 5th finger in it, keeping your fingers together and rock your hand towards the head allowing your pointer or 2nd finger to come to rest in the cricothyroid membrane (Video: Landmarking Alternative)

 

 

Prep area (considering the urgency of a cricothyrotomy, a quick scrub with antiseptic or saline solution should suffice. If less time pressured then adherence to proper sterile technique is encouraged - but usually unrealistic).

Make a vertical incision on the skin of the neck just below the thyroid cartilage with a scalpel (Video: Vertical Incision)

 

Re-identify the cricothyroid membrane (Video: Re-identify Cricothyroid membrane) and make a transverse (or horizontal) incision through the cricothyroid membrane (Video: Horizontal Incision & Horizontal Incision - Cross-section).

 

Using a tracheal hook pull the transected cricothyroid membrane open superiorly and pass the tracheal hook to assistant to hold or if no assistant is available place hook on inferior aspect of transected cricothyroid membrane and pull inferiorly to open trachea (Video: Placing Tracheal Hook & Placing Tracheal Hook - Cross-section).

 

Insert Trousseau dilator and dilate (Video: Inserting Trousseau Dilator & Inserting Trousseau Dilator Cross Section). If not available slide handle of scalpel into opening and turn 90 degrees to open and dilate further and place a bougie into airway if available.

 

Place 6.0 - 7.0 endotracheal tube or Shiley tracheostomy appliance into airway (Video: Inserting Shiley & Inserting Shiley – Cross-section) or overtop of boogie if utilized.

 

BEWARE of inserting Trousseau dilator so far into the airway as to obstruct the passage of the airway (Video: Beware of Trousseau airway obstruction – Cross-section).

 

Remove the Shiley airway appliance introducer (Video: Removing Shiley introducer) and place the removable airway within its internal diameter (Video: Inserting Shiley internal airway).

 

Blow up balloon and check the pressure of the Shiley bulb (Video: Balloon Inflation & Inflating Balloon - Cross-section)

Ensure placement by auscultation and observation of chest rising. A CO2 detection device may also be used.

Secure the device and check the tightness of this device that it will not put the patient at risk for skin necrosis secondary to pressure (Video: Checking Tie)

Videos of Surgical Cricothyrotomy Full Procedure & Surgical Cricothyrotomy Full Procedure - Cross-section available above

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Dec 18th, 2011 - Final Version

Feb 18, 2011 final Version II

December 18, 2011 final Version III

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